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General NPI Number Information
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NPI Number | 1720402431
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Entity Type | Organization
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Legal Business Name | BUILDING BLOCKS PEDIATRIC THERAPY
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Dates
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Enumeration Date | 02/17/2014
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Last Update Date | 04/12/2014
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Provider Practice Location Address
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Address Line | 1019 3RD ST
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City | LEWISTON
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State | ID
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Zip | 83501-2713
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Country | US
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Telephone | 208-818-4846
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Fax |
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Provider Business Mailing Address
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Address Line | 1019 3RD ST
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City | LEWISTON
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State | ID
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Zip | 83501-2713
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Country | US
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Telephone | 208-818-4846
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | JAMIE L LARSEN
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Credential | DPT
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Telephone | 208-816-4195
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | PT000010795
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | PT2265
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License Number State | ID
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