Provider Demographics
NPI:1154693364
Name:KALEIDOSCOPE PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:KALEIDOSCOPE PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:208-375-4200
Mailing Address - Street 1:7211 W FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-0926
Mailing Address - Country:US
Mailing Address - Phone:208-375-4200
Mailing Address - Fax:208-375-4201
Practice Address - Street 1:7211 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0926
Practice Address - Country:US
Practice Address - Phone:208-375-4200
Practice Address - Fax:208-375-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1860225100000X
IDOT-709225X00000X
IDSLP-1992235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1881962538Medicaid
ID1124199443Medicaid
ID1083876916Medicaid