Provider Demographics
NPI:1063083830
Name:EGGLESTON THERAPY LLC
Entity type:Organization
Organization Name:EGGLESTON THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OT
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:EGGLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:208-881-8362
Mailing Address - Street 1:8960 PARADISE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHINOOK
Mailing Address - State:MT
Mailing Address - Zip Code:59523-9387
Mailing Address - Country:US
Mailing Address - Phone:208-881-8362
Mailing Address - Fax:
Practice Address - Street 1:236 INDIANA ST
Practice Address - Street 2:
Practice Address - City:CHINOOK
Practice Address - State:MT
Practice Address - Zip Code:59523-9716
Practice Address - Country:US
Practice Address - Phone:406-344-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty