MEDICARE: FUNCTIONAL THERAPY 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	OT1249	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417235490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL THERAPY LLC

Provider Business Mailing Address
First Line	:	7533 CROOKED STICK DR
Second Line	:
City	:	DIAMONDHEAD
State	:	MS
Zip	:	39525-3895
Country	:	US
Telephone Number	:	228-255-8031
Fax Number	:	601-620-4117

Provider Business Practice Location Address
First Line	:	311 N MAIN ST
Second Line	:
City	:	PICAYUNE
State	:	MS
Zip	:	39466-3313
Country	:	US
Telephone Number	:	601-799-4065
Fax Number	:	601-620-4117

Authorized Official
Title or Position	:	OWNER
Name	:	STACEY S VOLLENWEIDER
Credential	:	OTR/L
Telephone Number	:	228-216-9996

Provider Enumeration Date	:	07/25/2011
Last Update Date	:	12/31/2014

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Directions to “FUNCTIONAL THERAPY LLC ” Practice Location

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