Healthcare Provider Details

I. General information

NPI: 1063125094
Provider Name (Legal Business Name): READY SET GROW PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 VOLUNTEER PKWY STE 400
BRISTOL TN
37620-4635
US

IV. Provider business mailing address

13 PENDLETON PL
KINGSPORT TN
37664-2169
US

V. Phone/Fax

Practice location:
  • Phone: 910-818-0977
  • Fax:
Mailing address:
  • Phone: 423-736-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SHALI NICOLE DENISON
Title or Position: CLINICAL DIRECTOR/OT
Credential: OTR/L
Phone: 423-736-7369