Healthcare Provider Details

I. General information

NPI: 1992172605
Provider Name (Legal Business Name): ATHENA THERAPY HOLDING CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 NILES CORTLAND RD NE
WARREN OH
44484-1938
US

IV. Provider business mailing address

4293 COLUMBIA RD
MEDINA OH
44256-7707
US

V. Phone/Fax

Practice location:
  • Phone: 330-609-5791
  • Fax:
Mailing address:
  • Phone: 330-410-3982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT009793
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT4846
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP8620
License Number StateOH

VIII. Authorized Official

Name: TERESA BRADFORD
Title or Position: PRESIDENT
Credential:
Phone: 330-410-3982