RED DOOR PEDIATRIC THERAPY, INC

Provider Demographics

• NPI: 1639257033
• Name: RED DOOR PEDIATRIC THERAPY, INC
• Entity type: Organization
• Organization Name: RED DOOR PEDIATRIC THERAPY, INC
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: FINANCIAL/CREDENTIALING
• Authorized Official - First Name: TIA-LEE
• Authorized Official - Last Name: WHITTED
• Authorized Official - Phone: 701-214-5617
• Mailing Address - Street 1: 2625 N 19TH ST
• Mailing Address - City: BISMARCK
• Mailing Address - State: ND
• Mailing Address - Zip Code: 58503-0574
• Mailing Address - Country: US
• Mailing Address - Phone: 701-222-3175
• Mailing Address - Fax: 701-222-3186
• Practice Address - Street 1: 2625 N 19TH ST
• Practice Address - City: BISMARCK
• Practice Address - State: ND
• Practice Address - Zip Code: 58503-0574
• Practice Address - Country: US
• Practice Address - Phone: 701-222-3175
• Practice Address - Fax: 701-222-3186
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-11-02
• Last Update Date: 2024-12-05

Provider Licenses

State	License ID	Taxonomies
		101YP2500X, 225100000X
ND	908	225X00000X
ND	862	235Z00000X, 235Z00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	235Z00000X	Speech, Language and Hearing Service Providers	Speech-Language Pathologist		Group - Multi-Specialty
No	101YP2500X	Behavioral Health & Social Service Providers	Counselor	Professional	Group - Multi-Specialty
No	225100000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Physical Therapist		Group - Multi-Specialty
No	225X00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
ND	1451283	Medicaid
ND	1461975	Medicaid
ND	1467615	Medicaid
ND	1469028	Medicaid
ND	1470224	Medicaid
ND	1480766	Medicaid
ND	1452184	Medicaid
ND	1454835	Medicaid
ND	1480013	Medicaid
ND	1468739	Medicaid
ND	1459139	Medicaid
ND	1461503	Medicaid
ND	1465117	Medicaid
ND	1465122	Medicaid
ND	1466654	Medicaid
ND	1474097	Medicaid
ND	1454897	Medicaid
ND	1459816	Medicaid
ND	1477950	Medicaid
ND	1477997	Medicaid
ND	1452040	Medicaid
ND	1463121	Medicaid
ND	1464384	Medicaid
ND	1464388	Medicaid
ND	1480833	Medicaid
ND	1454300	Medicaid
ND	1466867	Medicaid
ND	1468069	Medicaid
ND	1469164	Medicaid
ND	1476591	Medicaid
ND	1477752	Medicaid
ND	1450786	Medicaid
ND	1452036	Medicaid
ND	1454142	Medicaid
ND	1477918	Medicaid
ND	1481160	Medicaid