Provider Demographics
NPI:1033986294
Name:CANYON KIDS THERAPY LLC
Entity type:Organization
Organization Name:CANYON KIDS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR
Authorized Official - Phone:208-360-9969
Mailing Address - Street 1:9502 NOVACEK BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-2121
Mailing Address - Country:US
Mailing Address - Phone:208-360-9969
Mailing Address - Fax:
Practice Address - Street 1:9502 NOVACEK BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78254-2121
Practice Address - Country:US
Practice Address - Phone:208-360-9969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty