Provider Demographics
NPI:1558743013
Name:GREAT KIDS THERAPY, LTD
Entity Type:Organization
Organization Name:GREAT KIDS THERAPY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOFFMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:701-205-4194
Mailing Address - Street 1:3507 EVERGREEN RD N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-1218
Mailing Address - Country:US
Mailing Address - Phone:701-261-4643
Mailing Address - Fax:701-293-0981
Practice Address - Street 1:3120 25TH ST S STE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6110
Practice Address - Country:US
Practice Address - Phone:701-205-4194
Practice Address - Fax:701-540-9044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND345225X00000X
MN103207225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54371Medicaid
ND54375Medicaid