Healthcare Provider Details

I. General information

NPI: 1710040803
Provider Name (Legal Business Name): PEDIATRIC PHYSICAL THERAPY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 PROFESSIONAL CT
LAFAYETTE IN
47905-5152
US

IV. Provider business mailing address

80 PROFESSIONAL CT
LAFAYETTE IN
47905-5152
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-1758
  • Fax: 765-448-3898
Mailing address:
  • Phone: 765-448-1758
  • Fax: 765-448-3898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JAMIE SUE STORMONT-SMITH
Title or Position: OWNER PRESIDENT
Credential: PT PCS
Phone: 765-448-1758