Healthcare Provider Details

I. General information

NPI: 1770060964
Provider Name (Legal Business Name): SPROUT PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 SERENITY WAY
MADISON MS
39110-6992
US

IV. Provider business mailing address

108 SERENITY WAY
MADISON MS
39110-6992
US

V. Phone/Fax

Practice location:
  • Phone: 601-831-2360
  • Fax: 601-510-9735
Mailing address:
  • Phone: 601-831-2360
  • Fax: 601-510-9735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3255
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. EMILY R CUSTER
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: MS,PT
Phone: 601-831-2360