Provider Demographics
NPI:1760837728
Name:PEDS 2 POPS OT SERVICES
Entity Type:Organization
Organization Name:PEDS 2 POPS OT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:OOTHOUDT
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:603-729-0056
Mailing Address - Street 1:4 PEABODY ST
Mailing Address - Street 2:
Mailing Address - City:TILTON
Mailing Address - State:NH
Mailing Address - Zip Code:03276-5407
Mailing Address - Country:US
Mailing Address - Phone:603-729-0056
Mailing Address - Fax:603-729-0069
Practice Address - Street 1:4 PEABODY ST
Practice Address - Street 2:
Practice Address - City:TILTON
Practice Address - State:NH
Practice Address - Zip Code:03276-5407
Practice Address - Country:US
Practice Address - Phone:603-729-0056
Practice Address - Fax:603-729-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-27
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2551225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty