Provider Demographics
NPI:1669877056
Name:BLUEPRINT PEDIATRIC THERAPY, PLC
Entity type:Organization
Organization Name:BLUEPRINT PEDIATRIC THERAPY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KONGSHAUG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, PCS
Authorized Official - Phone:319-333-4490
Mailing Address - Street 1:2387 MEHAFFEY BRIDGE RD NE
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9348
Mailing Address - Country:US
Mailing Address - Phone:319-333-4490
Mailing Address - Fax:
Practice Address - Street 1:2387 MEHAFFEY BRIDGE RD NE
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9348
Practice Address - Country:US
Practice Address - Phone:319-333-4490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA3530261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy