Provider Demographics
NPI:1568973436
Name:PORGY AND PETUNIA PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:PORGY AND PETUNIA PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGENA
Authorized Official - Middle Name:
Authorized Official - Last Name:YANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:484-388-9729
Mailing Address - Street 1:516 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-4219
Mailing Address - Country:US
Mailing Address - Phone:484-388-9729
Mailing Address - Fax:
Practice Address - Street 1:7 RIGGAN LANE
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4301
Practice Address - Country:US
Practice Address - Phone:484-388-9729
Practice Address - Fax:484-388-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
IDID-945225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty