Provider Demographics
NPI:1255879599
Name:NORTHLAND PEDIATRIC PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:NORTHLAND PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUYSER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-535-0011
Mailing Address - Street 1:6609 ROYAL ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-8737
Mailing Address - Country:US
Mailing Address - Phone:816-535-0011
Mailing Address - Fax:816-535-0377
Practice Address - Street 1:6609 ROYAL ST STE 103
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64068-8737
Practice Address - Country:US
Practice Address - Phone:816-535-0011
Practice Address - Fax:816-535-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000167618261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy