Provider Demographics
NPI:1194125617
Name:IDAHO PEDIATRIC THERAPY CLINIC PLLC
Entity type:Organization
Organization Name:IDAHO PEDIATRIC THERAPY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGORIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-939-3334
Mailing Address - Street 1:3080 E GENTRY WAY STE 180
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3544
Mailing Address - Country:US
Mailing Address - Phone:089-393-3342
Mailing Address - Fax:208-939-1122
Practice Address - Street 1:3080 E GENTRY WAY STE 180
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3544
Practice Address - Country:US
Practice Address - Phone:208-939-3334
Practice Address - Fax:208-939-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1450225100000X
IDOT-928225X00000X
IDSLP-2249235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1194125617Medicaid
ID1013086610Medicaid