Provider Demographics
NPI:1922443522
Name:FUNDAMENTAL KIDS THERAPY LLC
Entity Type:Organization
Organization Name:FUNDAMENTAL KIDS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:952-297-2460
Mailing Address - Street 1:5985 RICE CREEK PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5037
Mailing Address - Country:US
Mailing Address - Phone:612-888-4757
Mailing Address - Fax:612-808-0005
Practice Address - Street 1:5985 RICE CREEK PKWY STE 205
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5037
Practice Address - Country:US
Practice Address - Phone:612-888-4757
Practice Address - Fax:612-808-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
MN8614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty