Provider Demographics
NPI:1083759021
Name:FUNCTIONAL THERAPY
Entity Type:Organization
Organization Name:FUNCTIONAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:PASOL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:907-334-9002
Mailing Address - Street 1:PO BOX 113394
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-3394
Mailing Address - Country:US
Mailing Address - Phone:907-334-9002
Mailing Address - Fax:907-334-9320
Practice Address - Street 1:6613 BRAYTON DR
Practice Address - Street 2:SUITE A
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-2127
Practice Address - Country:US
Practice Address - Phone:907-334-9002
Practice Address - Fax:907-334-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2251P0200X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Not Answered225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOT32411Medicaid
AKOT45641Medicaid
AKOT1318Medicaid
AKPT2352Medicaid