Provider Demographics
NPI:1720402431
Name:BUILDING BLOCKS PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:BUILDING BLOCKS PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-816-4195
Mailing Address - Street 1:1019 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2713
Mailing Address - Country:US
Mailing Address - Phone:208-818-4846
Mailing Address - Fax:
Practice Address - Street 1:1019 3RD ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2713
Practice Address - Country:US
Practice Address - Phone:208-818-4846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-17
Last Update Date:2014-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT22652251P0200X
WAPT0000107952251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty