Basic Information
| Provider Information | |||||||||
| NPI: | 1649269358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL THERAPY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1234 WHITEFISH STAGE | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599012753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067567878 | ||||||||
| FaxNumber: | 4062577811 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 WHITEFISH STAGE | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599012753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067567878 | ||||||||
| FaxNumber: | 4062577811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GIBBS | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4067567878 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT OCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 767 | 01 | MT | WA ST WORK COMP GRP PROV# | OTHER |