Provider Demographics
NPI:1831444504
Name:PEDIATRIC SENSORY THERAPY, LLC
Entity type:Organization
Organization Name:PEDIATRIC SENSORY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOULD-YORK
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L
Authorized Official - Phone:503-477-9527
Mailing Address - Street 1:6635 N BALTIMORE AVE
Mailing Address - Street 2:SUITE 228
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5454
Mailing Address - Country:US
Mailing Address - Phone:503-477-9527
Mailing Address - Fax:
Practice Address - Street 1:6635 N BALTIMORE AVE
Practice Address - Street 2:SUITE 228
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-5454
Practice Address - Country:US
Practice Address - Phone:503-477-9527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1076095225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR273905Medicaid