Provider Demographics
NPI:1841854163
Name:PEDIATRIC OCCUPATIONAL THERAPY SOLUTIONS, LLC
Entity type:Organization
Organization Name:PEDIATRIC OCCUPATIONAL THERAPY SOLUTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIEDRA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PINE
Authorized Official - Suffix:
Authorized Official - Credentials:OTL
Authorized Official - Phone:503-997-1309
Mailing Address - Street 1:4548 NE HOLMAN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-1349
Mailing Address - Country:US
Mailing Address - Phone:503-997-1309
Mailing Address - Fax:971-888-5266
Practice Address - Street 1:5220 NE SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2666
Practice Address - Country:US
Practice Address - Phone:503-997-1309
Practice Address - Fax:971-888-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500189782Medicaid