Basic Information
| Provider Information | |||||||||
| NPI: | 1811388119 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROGUE PEDIATRIC THERAPIES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ABN OF MORE THAN WORDS SPEECH THERAPY, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 EARHART ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975017828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418164747 | ||||||||
| FaxNumber: | 5417874011 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 EARHART ST | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975017828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418164747 | ||||||||
| FaxNumber: | 5417874011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2015 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GALLAGHER | ||||||||
| AuthorizedOfficialFirstName: | DENELL | ||||||||
| AuthorizedOfficialMiddleName: | MARTHA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5418164747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, CCC-SLP | ||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 14054 | OR | N | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.