Provider Demographics
NPI:1366964538
Name:BOLD PEDIATRIC THERAPY CENTER INC
Entity type:Organization
Organization Name:BOLD PEDIATRIC THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR /OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PELHAM-FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, MPHA, OTR/L
Authorized Official - Phone:503-313-7333
Mailing Address - Street 1:409 NE BIRCHWOOD TER
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-3219
Mailing Address - Country:US
Mailing Address - Phone:1503-313-7333
Mailing Address - Fax:
Practice Address - Street 1:1815 NW 169TH PL STE 3070
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7368
Practice Address - Country:US
Practice Address - Phone:971-249-2653
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty