Organization
IDAHO PEDIATRIC THERAPY CLINIC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER LONGORIA (OFFICE MANAGER)
(208) 939-3334
Entity
Organization
Contact information
Practice address
3080 E GENTRY WAY STE 180, MERIDIAN, ID 83642-3544
(208) 939-3334
(208) 939-1122
Mailing address
3080 E GENTRY WAY STE 180, MERIDIAN, ID 83642-3544
(089) 393-3342
(208) 939-1122
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT-1450
ID
225X00000X
Occupational Therapist
OT-928
ID
235Z00000X
Speech-Language Pathologist
SLP-2249
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1013086610
—
ID
05
—
1194125617
—
ID
Enumeration date
09/03/2014
Last updated
07/09/2019
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