MEDICARE: GRASSROOTS THERAPY SOLUTIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT2925	MS

General Provider Information

NPI Number	:	1386036911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRASSROOTS THERAPY SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	1057 MONROE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202-2730
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1057 MONROE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202-2730
Country	:	US
Telephone Number	:	662-497-0485
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHANIE MIMMS
Credential	:	MOTR/L
Telephone Number	:	662-497-0485

Provider Enumeration Date	:	02/18/2015
Last Update Date	:	02/18/2015

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