Provider Demographics
NPI:1730531005
Name:MOVING UP PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:MOVING UP PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCPHIE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:307-672-5631
Mailing Address - Street 1:625 E 5TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3171
Mailing Address - Country:US
Mailing Address - Phone:307-672-5631
Mailing Address - Fax:
Practice Address - Street 1:625 E 5TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3171
Practice Address - Country:US
Practice Address - Phone:307-672-5631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR 586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYPENDINGMedicaid