Provider Demographics
NPI:1861912792
Name:PEDIATRIC POTENTIALS
Entity type:Organization
Organization Name:PEDIATRIC POTENTIALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:OCCUPATIONAL THERAPY
Authorized Official - Phone:406-582-4182
Mailing Address - Street 1:519 E FRIDLEY ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3717
Mailing Address - Country:US
Mailing Address - Phone:406-582-4182
Mailing Address - Fax:406-582-4148
Practice Address - Street 1:1122 E MAIN ST STE 4
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3888
Practice Address - Country:US
Practice Address - Phone:406-582-4182
Practice Address - Fax:406-582-4148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT863225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty