Healthcare Provider Details

I. General information

NPI: 1205628625
Provider Name (Legal Business Name): NOURISH PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 W 110TH ST STE 220
OVERLAND PARK KS
66210-2402
US

IV. Provider business mailing address

8400 W 110TH ST STE 220
OVERLAND PARK KS
66210-2402
US

V. Phone/Fax

Practice location:
  • Phone: 913-210-0574
  • Fax: 913-428-5521
Mailing address:
  • Phone: 913-210-0574
  • Fax: 913-428-5521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANDREA SOUTHARD
Title or Position: FOUNDER
Credential: MOTR/L
Phone: 913-660-6883