Kidspace Therapy, LLC

Primary specialty

Developmental Disabilities Clinic/CenterTaxonomy code 261QD1600X

License

603464065 Issued in WA

Legal business name

KIDSPACE THERAPY, LLC

Practice address

2145 Tibbetts Dr Ste a
Longview, WA 98632-4211

Phone

(360) 560-1972

Fax

(360) 703-3452

NPI assigned

Apr 6, 2015

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Leslie Kay Wolff, OTR/L

Title

Owner

Phone

(360) 560-1972

Specialties & licenses 2

Addresses

Other identifiers 3

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Kelly Baierl, MS, CCC-SLP

  • Speech-Language Pathologist
  • Longview, WA
  • NPI 1629569181
  NPD (past)
• Karrie Janae Petersen, MS, CCC- SLP

  • Speech-Language Pathologist
  • Vancouver, WA
  • NPI 1346591153
  NPD (past)
• McKinzi M Pontious, OTR/L

  • Pediatric Occupational Therapist
  • Vancouver, WA
  • NPI 1861990533
  NPD (past)
• Leah Ann Tyler Stoutt

  • Speech-Language Pathologist
  • Oregon City, OR
  • NPI 1154813590
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1428278400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1594771200000",
    "number": "1184019184",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2145 TIBBETTS DR STE A",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986324211",
            "telephone_number": "360-560-1972",
            "fax_number": "360-703-3452"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2145 TIBBETTS DR STE A",
            "city": "LONGVIEW",
            "state": "WA",
            "postal_code": "986324211",
            "telephone_number": "360-560-1972",
            "fax_number": "360-703-3452"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KIDSPACE THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-06",
        "last_updated": "2020-07-15",
        "certification_date": "2020-07-15",
        "status": "A",
        "authorized_official_last_name": "WOLFF",
        "authorized_official_first_name": "LESLIE",
        "authorized_official_middle_name": "KAY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "360-560-1972",
        "authorized_official_credential": "OTR/L"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "WA",
            "license": "OT00001294",
            "primary": false
        },
        {
            "code": "261QD1600X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Developmental Disabilities",
            "state": "WA",
            "license": "603464065",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1801921531",
            "state": "WA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2043730",
            "state": "WA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UBI",
            "identifier": "603464065",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Bryan Kerr, C.D.P.
• Amanda M Kersteter, MC, LMHC, MHP, CMHS
• Jan Carlin Khouri, APRN
• Gregory G Khurtsidze, M.D.
• Ansab Khwaja, MD PC
• Sheryl A Kiel, LICSW
• Deirdre K Kiest, LMP
• John Wallace Kilbourn, RPH
• Bria Moira Killgore, MSW, CHES
• Emily Killham

• All providers in Longview, WA
• Developmental Disabilities Clinic/Center in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 15, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.