Provider Demographics
NPI:1902520828
Name:OUR VILLAGE THERAPY, PLLC
Entity Type:Organization
Organization Name:OUR VILLAGE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALTHER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:919-417-7259
Mailing Address - Street 1:7316 RIDGE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5908
Mailing Address - Country:US
Mailing Address - Phone:919-417-7259
Mailing Address - Fax:
Practice Address - Street 1:7316 RIDGE GROVE CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5908
Practice Address - Country:US
Practice Address - Phone:919-417-7259
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XF0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistFeeding, Eating & SwallowingGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134462872Medicaid