MEDICARE: HOMETOWN PEDIATRIC THERAPY SERVICES

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	225XP0200X	Pediatric Occupational Therapist
2	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1841916707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOMETOWN PEDIATRIC THERAPY SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 332
Second Line	:
City	:	CHARLESTON
State	:	AR
Zip	:	72933-0332
Country	:	US
Telephone Number	:	479-275-9150
Fax Number	:	479-662-4766

Provider Business Practice Location Address
First Line	:	1811 E MAIN ST
Second Line	:
City	:	CHARLESTON
State	:	AR
Zip	:	72933-9254
Country	:	US
Telephone Number	:	479-275-9150
Fax Number	:	479-662-4766

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL DEREK LAW
Credential	:	OTR/L
Telephone Number	:	479-275-9150

Provider Enumeration Date	:	10/12/2022
Last Update Date	:	07/14/2025

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