Provider Demographics
NPI:1033649694
Name:BRIGHT SPOT PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:BRIGHT SPOT PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSKAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-850-8154
Mailing Address - Street 1:1425 N KILLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4541
Mailing Address - Country:US
Mailing Address - Phone:503-850-8154
Mailing Address - Fax:844-234-8735
Practice Address - Street 1:1425 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4541
Practice Address - Country:US
Practice Address - Phone:503-575-9402
Practice Address - Fax:888-769-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X, 225XP0200X
OR1042968225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500796699Medicaid