Healthcare Provider Details

I. General information

NPI: 1801218797
Provider Name (Legal Business Name): NANTUCKET THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ORANGE ST
NANTUCKET MA
02554-4028
US

IV. Provider business mailing address

125 ORANGE ST
NANTUCKET MA
02554-4028
US

V. Phone/Fax

Practice location:
  • Phone: 508-648-8348
  • Fax: 508-796-6262
Mailing address:
  • Phone: 508-648-8348
  • Fax: 508-796-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number8216
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8082
License Number StateMA

VIII. Authorized Official

Name: CARYNNE A KEYES
Title or Position: OWNER/DIRECTOR
Credential: MA, CCC-SLP
Phone: 508-648-8348