NPIMap

Organization Active NPI

Proactive Pediatric Therapy, LLC

  • Rehabilitation Clinic/Center
  • Hiawatha, IA
National Provider Identifier
1679121933
Registry record updated Feb 26, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rehabilitation Clinic/CenterTaxonomy code 261QR0400X
Legal business name
PROACTIVE PEDIATRIC THERAPY, LLC
Practice address
1717 Boyson Rd
Hiawatha, IA 52233-2313
Phone
(319) 721-9333
NPI assigned
Aug 29, 2019
Last updated
Feb 26, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 26, 2020

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

Authorized official

Name
Lisa Dolphin, OTNPI 1831749969
Title
Manager
Phone
(319) 721-9333

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Physical Therapist 2251P0200X NU
Pediatric Occupational Therapist 225XP0200X NU
Speech-Language Pathologist 235Z00000X NU
Rehabilitation Clinic/Center 261QR0400X NU Primary
Lactation Consultant (Non-RN) 174N00000X NU
Feeding, Eating & Swallowing Occupational Therapist 225XF0002X NU

Addresses

Primary practice location

1717 Boyson Rd
Hiawatha, IA 52233-2313

Mailing address

1717 Boyson Rd
Hiawatha, IA 52233-2313
Phone (319) 721-9333

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address lisa@proactivepediatrictherapy.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190925000301 IA Part A Provider - Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services 9537499132 Practice locations: Hiawatha, IA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1679121933. Details of each certification follow.

  • CCN 166614 Outpatient physical therapy / speech pathology · Active · Name & address match · Details

Outpatient physical therapy / speech pathology certification: CCN 166614

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
PROACTIVE PEDIATIRIC THERAPY, LLC
Certification status
Active
Provider type (POS)
Outpatient physical therapy / speech pathology
Participating since
Jan 17, 2020
Last certification
Jan 17, 2020
Ownership / control type
Proprietary
Facility address
1717 Boyson Road
Hiawatha, IA 52233

National Provider Directory

National Provider Directory

Locations

1717 Boyson Rd
Hiawatha, IA 52233
Phone (319) 200-2004

Practitioners & affiliated clinicians

Practitioners 20

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 20

NPI Registry JSON

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

{
    "created_epoch": "1567036800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1582675200000",
    "number": "1679121933",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1717 BOYSON RD",
            "city": "HIAWATHA",
            "state": "IA",
            "postal_code": "522332313",
            "telephone_number": "319-721-9333"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1717 BOYSON RD",
            "city": "HIAWATHA",
            "state": "IA",
            "postal_code": "522332313",
            "telephone_number": "319-721-9333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROACTIVE PEDIATRIC THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-08-29",
        "last_updated": "2020-02-26",
        "certification_date": "2020-02-26",
        "status": "A",
        "authorized_official_last_name": "DOLPHIN",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "319-721-9333",
        "authorized_official_credential": "OT"
    },
    "taxonomies": [
        {
            "code": "2251P0200X",
            "taxonomy_group": "",
            "desc": "Physical Therapist, Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "225XP0200X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist, Pediatrics",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "174N00000X",
            "taxonomy_group": "",
            "desc": "Lactation Consultant, Non-RN",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "225XF0002X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist, Feeding, Eating & Swallowing",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "lisa@proactivepediatrictherapy.com",
            "affiliation": "N",
            "endpointDescription": "email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "1717 Boyson Rd",
            "city": "Hiawatha",
            "state": "IA",
            "country_code": "US",
            "postal_code": "522332313",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Hiawatha, IA

Sources for this page

Verify at the official NPI Registry.