Provider Demographics
NPI:1477886232
Name:CHILDRENS INTENSIVE THERAPY NORTHWEST
Entity Type:Organization
Organization Name:CHILDRENS INTENSIVE THERAPY NORTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BRAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-570-5043
Mailing Address - Street 1:12948 SE WINSTON RD
Mailing Address - Street 2:
Mailing Address - City:DAMASCUS
Mailing Address - State:OR
Mailing Address - Zip Code:97089-7606
Mailing Address - Country:US
Mailing Address - Phone:971-570-5043
Mailing Address - Fax:
Practice Address - Street 1:7203 SE RAYMOND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4323
Practice Address - Country:US
Practice Address - Phone:503-895-1320
Practice Address - Fax:503-296-2319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR49702251P0200X
OR56802251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty