Provider Demographics
NPI:1821407867
Name:FOUR RAVENS OCCUPATIONAL THERAPY LLC
Entity Type:Organization
Organization Name:FOUR RAVENS OCCUPATIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MAGGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOTCH
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L
Authorized Official - Phone:907-766-2101
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:HAINES
Mailing Address - State:AK
Mailing Address - Zip Code:99827-0778
Mailing Address - Country:US
Mailing Address - Phone:907-766-2101
Mailing Address - Fax:907-766-2104
Practice Address - Street 1:69 BEACH ROAD
Practice Address - Street 2:
Practice Address - City:HAINES
Practice Address - State:AK
Practice Address - Zip Code:99827-0778
Practice Address - Country:US
Practice Address - Phone:907-766-2101
Practice Address - Fax:907-766-2104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1660225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1023560Medicaid
ORR167353Medicare PIN