Healthcare Provider Details

I. General information

NPI: 1225414717
Provider Name (Legal Business Name): THROUGH THE ROOF PEDIATRIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 MILAM LN
HERNANDO MS
38632-7719
US

IV. Provider business mailing address

1895 THOUSAND OAKS DR
HERNANDO MS
38632-8914
US

V. Phone/Fax

Practice location:
  • Phone: 901-568-2240
  • Fax:
Mailing address:
  • Phone: 901-568-2240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT2977
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS3688
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT0828
License Number StateMS

VIII. Authorized Official

Name: DONNA B SULARIN
Title or Position: EXECUTIVE DIRECTOR, P.T.
Credential: P.T,
Phone: 901-568-2240