Provider Demographics
NPI:1144795717
Name:SKILL BUILDERZ PEDIATRIC THERAPY, LLC
Entity Type:Organization
Organization Name:SKILL BUILDERZ PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITTENESS
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L, BCBA
Authorized Official - Phone:701-330-8009
Mailing Address - Street 1:4133 IOWA ST STE 210
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3316
Mailing Address - Country:US
Mailing Address - Phone:701-330-8009
Mailing Address - Fax:
Practice Address - Street 1:4133 IOWA ST STE 210
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3316
Practice Address - Country:US
Practice Address - Phone:701-330-8009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty