Healthcare Provider Details

I. General information

NPI: 1588098412
Provider Name (Legal Business Name): SPROUT PEDIATRIC OCCUPATIONAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N ROCK RD, BLDG 2200, STE 101
WICHITA KS
67226-1341
US

IV. Provider business mailing address

PO BOX 17053
WICHITA KS
67217-0053
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-3316
  • Fax: 888-965-6885
Mailing address:
  • Phone: 316-944-3940
  • Fax: 316-946-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1701783
License Number StateKS

VIII. Authorized Official

Name: SHAWNA MARIE WENDT
Title or Position: OWNER
Credential: OTR/L,BCP
Phone: 316-440-3316