=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346370640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACHIEVE THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 01/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3035 DEMERS AVE
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-4040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-746-6694
-----------------------------------------------------
Fax | 701-746-6894
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3035 DEMERS AVE
-----------------------------------------------------
City | GRAND FORKS
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58201-4040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-746-6694
-----------------------------------------------------
Fax | 701-746-6894
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHELLE D ELLIS
-----------------------------------------------------
Credential | ATC, PTA
-----------------------------------------------------
Telephone | 701-746-8374
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------