Provider Demographics
NPI:1275937013
Name:CIRQUE THERAPY, LLC
Entity Type:Organization
Organization Name:CIRQUE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:907-756-1101
Mailing Address - Street 1:PO BOX 2157
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-2157
Mailing Address - Country:US
Mailing Address - Phone:907-756-1101
Mailing Address - Fax:
Practice Address - Street 1:653 W FAIRVIEW AVE
Practice Address - Street 2:APT I
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7444
Practice Address - Country:US
Practice Address - Phone:907-756-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2854225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty