Provider Demographics
NPI:1376677914
Name:NORTHLAND-RURAL THERAPY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:NORTHLAND-RURAL THERAPY ASSOCIATES, LLC
Other - Org Name:NORTHLAND-RURAL THERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:COSNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-779-1679
Mailing Address - Street 1:2915 NORTH 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-779-1679
Mailing Address - Fax:928-779-2822
Practice Address - Street 1:2915 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004
Practice Address - Country:US
Practice Address - Phone:928-779-1679
Practice Address - Fax:928-779-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ872714OtherAHCCCS NUMBER
AZ872714Medicaid
AZ872714Medicaid