Provider Demographics
NPI:1972603454
Name:EARTH ANGELS THERAPY, LLC
Entity type:Organization
Organization Name:EARTH ANGELS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PALATNIK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:623-521-5387
Mailing Address - Street 1:10101 N 91ST AVE
Mailing Address - Street 2:#112
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8335
Mailing Address - Country:US
Mailing Address - Phone:623-521-5387
Mailing Address - Fax:866-896-0786
Practice Address - Street 1:10101 N 91ST AVE
Practice Address - Street 2:#112
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8335
Practice Address - Country:US
Practice Address - Phone:623-521-5387
Practice Address - Fax:866-896-0786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-24
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0311225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ987688OtherAHCCCS PROVIDER