Healthcare Provider Details

I. General information

NPI: 1932714888
Provider Name (Legal Business Name): ELEVATION THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 CUMBERLAND AVE
MIDDLESBORO KY
40965-1223
US

IV. Provider business mailing address

1510 CUMBERLAND AVE
MIDDLESBORO KY
40965-1223
US

V. Phone/Fax

Practice location:
  • Phone: 606-269-5043
  • Fax: 606-302-5418
Mailing address:
  • Phone: 606-269-5043
  • Fax: 606-302-5418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JAMES T CORUM JR.
Title or Position: PRESIDENT/DPT
Credential: DPT, COMT, CERT MDT
Phone: 606-269-5043