Provider Demographics
NPI:1790189025
Name:OPTIMAL THERAPY FOR KIDS, LLC
Entity type:Organization
Organization Name:OPTIMAL THERAPY FOR KIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SASCHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GERVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-453-6335
Mailing Address - Street 1:1145 ROCK CREEK DR S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-2222
Mailing Address - Country:US
Mailing Address - Phone:503-453-6335
Mailing Address - Fax:
Practice Address - Street 1:1145 ROCK CREEK DR S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-2222
Practice Address - Country:US
Practice Address - Phone:503-453-6335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR306415225XP0200X
OR44692251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty