NPIMap

Organization Active NPI

Fundamental Kids Therapy LLC

  • Speech-Language Pathologist
  • Shoreview, MN
National Provider Identifier
1922443522
Registry record updated Oct 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Speech-Language PathologistTaxonomy code 235Z00000X
License
8614 Issued in MN
Legal business name
FUNDAMENTAL KIDS THERAPY LLC
Practice address
5985 Rice Creek Pkwy Ste 205
Shoreview, MN 55126-5037
Phone
(612) 888-4757
Fax
(612) 808-0005
NPI assigned
May 8, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 17, 2021

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

Authorized official

Name
Mrs. Julie M Johnson, MA, CCC-SLPNPI 1689946006
Title
Owner
Phone
(952) 297-2460

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 2

Specialty (taxonomy)CodeLicenseStatePrimary
Occupational TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225X00000X
Speech-Language PathologistGroup: 193200000X MULTI-SPECIALTY GROUP 235Z00000X 8614 MN Primary

Addresses

Primary practice location

5985 Rice Creek Pkwy Ste 205
Shoreview, MN 55126-5037

Mailing address

5985 Rice Creek Pkwy Ste 205
Shoreview, MN 55126-5037
Phone (612) 888-4757

Other practice location 1

12732 Lake Blvd
Lindstrom, MN 55045-9342
Phone (612) 888-4757

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20170106000939 MN Part B Supplier - Clinic/Group Practice 7810278835 Receives reassigned benefits from 4 practitioners
Practice locations: Shoreview, MN

National Provider Directory

National Provider Directory

Locations

5985 Rice Creek Pkwy
Ste 205
Shoreview, MN 55126
Phone (612) 888-4757

Practitioners & affiliated clinicians

Practitioners 5

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

NPI Registry JSON

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

{
    "created_epoch": "1367971200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634428800000",
    "number": "1922443522",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5985 RICE CREEK PKWY STE 205",
            "city": "SHOREVIEW",
            "state": "MN",
            "postal_code": "551265037",
            "telephone_number": "612-888-4757",
            "fax_number": "612-808-0005"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5985 RICE CREEK PKWY STE 205",
            "city": "SHOREVIEW",
            "state": "MN",
            "postal_code": "551265037",
            "telephone_number": "612-888-4757",
            "fax_number": "612-808-0005"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "12732 Lake Blvd",
            "address_purpose": "LOCATION",
            "city": "Lindstrom",
            "state": "MN",
            "postal_code": "550459342",
            "country_code": "US",
            "telephone_number": "612-888-4757",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "FUNDAMENTAL KIDS THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-05-08",
        "last_updated": "2021-10-17",
        "certification_date": "2021-10-17",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "JULIE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "952-297-2460",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MA, CCC-SLP"
    },
    "taxonomies": [
        {
            "code": "225X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Speech-Language Pathologist",
            "state": "MN",
            "license": "8614",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Shoreview, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 17, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.