Provider Demographics
NPI:1164055513
Name:EXPRESSION PEDIATRIC THERAPY, PLLC
Entity Type:Organization
Organization Name:EXPRESSION PEDIATRIC THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOODWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:509-981-3998
Mailing Address - Street 1:2212 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2414
Mailing Address - Country:US
Mailing Address - Phone:509-981-3998
Mailing Address - Fax:
Practice Address - Street 1:1340 W VILLARD ST STE A
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4632
Practice Address - Country:US
Practice Address - Phone:701-590-9116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-13
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty