Basic Information
Provider Information | |||||||||
NPI: | 1467995084 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEUROTHERAPEUTIC PEDIATRIC THERAPIES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDFORD CHILDREN'S THERAPY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 113 N ELM ST | ||||||||
Address2: |   | ||||||||
City: | CANBY | ||||||||
State: | OR | ||||||||
PostalCode: | 97013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032638903 | ||||||||
FaxNumber: | 5032668632 | ||||||||
Practice Location | |||||||||
Address1: | 400 CRATER LAKE AVE | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | OR | ||||||||
PostalCode: | 975046808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5416136505 | ||||||||
FaxNumber: | 5417709212 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/30/2016 | ||||||||
LastUpdateDate: | 11/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WATTERS | ||||||||
AuthorizedOfficialFirstName: | AMANDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5032638903 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NEUROTHERAPEUTIC PEDIATRIC THERAPIES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | ND | ||||||||
NPICertificationDate: | 11/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175F00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Naturopath |   | 225100000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 2251P0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225XP0200X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 225X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 500718434 | 05 | OR |   | MEDICAID |