Provider Demographics
NPI:1184019184
Name:KIDSPACE THERAPY, LLC
Entity type:Organization
Organization Name:KIDSPACE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:360-560-1972
Mailing Address - Street 1:2145 TIBBETTS DR STE A
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4211
Mailing Address - Country:US
Mailing Address - Phone:360-560-1972
Mailing Address - Fax:360-703-3452
Practice Address - Street 1:2145 TIBBETTS DR STE A
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4211
Practice Address - Country:US
Practice Address - Phone:360-560-1972
Practice Address - Fax:360-703-3452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00001294261Q00000X
WA603464065261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1801921531OtherINDIVIDUAL NPI
WA2043730Medicaid
WA603464065OtherUBI