Healthcare Provider Details

I. General information

NPI: 1033289749
Provider Name (Legal Business Name): SPORTS REHAB AND PROFESSIONAL THERAPY ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W 5TH ST
STORM LAKE IA
50588-1743
US

IV. Provider business mailing address

315 W 5TH ST
STORM LAKE IA
50588-1743
US

V. Phone/Fax

Practice location:
  • Phone: 712-732-7724
  • Fax: 712-560-9253
Mailing address:
  • Phone: 712-732-7724
  • Fax: 712-732-5153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THERESA LYNN GODFREY
Title or Position: CLINIC ADMIN DIRECTOR
Credential:
Phone: 402-334-6025