Provider Demographics
NPI:1336293315
Name:PEDIATRIC NDT & SI THERAPY SERVICES, INC.
Entity Type:Organization
Organization Name:PEDIATRIC NDT & SI THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCNUTT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:360-398-2772
Mailing Address - Street 1:348 W KING TUT RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9652
Mailing Address - Country:US
Mailing Address - Phone:360-398-2772
Mailing Address - Fax:360-398-2772
Practice Address - Street 1:348 W KING TUT RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9652
Practice Address - Country:US
Practice Address - Phone:360-398-2772
Practice Address - Fax:360-398-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2251P0200X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7680911Medicaid