Provider Demographics
NPI:1568182020
Name:PLAY ADVENTURES PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:PLAY ADVENTURES PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:(SPEECH THERAPIST) OWNER/PARTER
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MESSICK
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:208-305-7076
Mailing Address - Street 1:3232 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4660
Mailing Address - Country:US
Mailing Address - Phone:208-305-7076
Mailing Address - Fax:
Practice Address - Street 1:247 THAIN RD STE 104
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4800
Practice Address - Country:US
Practice Address - Phone:208-305-7076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty