MEDICARE: OPTIMAL THERAPY FOR KIDS, 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	306415	OR
2	2251P0200X	Pediatric Physical Therapist	4469	OR

General Provider Information

NPI Number	:	1790189025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL THERAPY FOR KIDS, LLC

Provider Business Mailing Address
First Line	:	1145 ROCK CREEK DR S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97306-2222
Country	:	US
Telephone Number	:	503-453-6335
Fax Number	:

Provider Business Practice Location Address
First Line	:	1145 ROCK CREEK DR S
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97306-2222
Country	:	US
Telephone Number	:	503-453-6335
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	SASCHA GERVAIS
Credential	:	PT
Telephone Number	:	503-453-6335

Provider Enumeration Date	:	10/15/2014
Last Update Date	:	10/15/2014

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Directions to “OPTIMAL THERAPY FOR KIDS, LLC ” Practice Location

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