Healthcare Provider Details

I. General information

NPI: 1063985885
Provider Name (Legal Business Name): SOUTHERN PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1772 CARLEE DR
HERNANDO MS
38632-8844
US

IV. Provider business mailing address

PO BOX 441
HERNANDO MS
38632-0441
US

V. Phone/Fax

Practice location:
  • Phone: 662-469-2906
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER PACILEO
Title or Position: OWNER
Credential: OTR/L
Phone: 662-469-2906