Provider Demographics
NPI:1053186825
Name:PODERA THERAPY PLLC
Entity type:Organization
Organization Name:PODERA THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-244-1702
Mailing Address - Street 1:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:CEDAR VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84013-0174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8176 N OCONNELL LN
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5813
Practice Address - Country:US
Practice Address - Phone:385-351-5473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty