Provider Demographics
NPI:1003984394
Name:ESI THERAPY, PC
Entity Type:Organization
Organization Name:ESI THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ETHELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:480-882-1737
Mailing Address - Street 1:30230 N ROYAL OAK WAY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-4324
Mailing Address - Country:US
Mailing Address - Phone:480-882-1737
Mailing Address - Fax:480-882-1915
Practice Address - Street 1:30230 N ROYAL OAK WAY
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85243-4324
Practice Address - Country:US
Practice Address - Phone:480-882-1737
Practice Address - Fax:480-882-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDDD704011225100000X, 225X00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ794398Medicaid