MEDICARE: GROUNDPLAY THERAPY WORKS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	1054642	OR

General Provider Information

NPI Number	:	1306284542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROUNDPLAY THERAPY WORKS, LLC

Provider Business Mailing Address
First Line	:	2029 NE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5305
Country	:	US
Telephone Number	:	971-888-5265
Fax Number	:	971-888-5266

Provider Business Practice Location Address
First Line	:	2029 NE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97212-5305
Country	:	US
Telephone Number	:	971-888-5265
Fax Number	:	971-888-5266

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAELA A KISTLER
Credential	:
Telephone Number	:	971-888-5265

Provider Enumeration Date	:	06/10/2013
Last Update Date	:	08/08/2025

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