Healthcare Provider Details

I. General information

NPI: 1033593785
Provider Name (Legal Business Name): CAN DO KIDS PEDIATRIC THERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MOUSE CREEK RD NW
CLEVELAND TN
37312-4840
US

IV. Provider business mailing address

65 MOUSE CREEK RD NW
CLEVELAND TN
37312-4840
US

V. Phone/Fax

Practice location:
  • Phone: 423-476-7212
  • Fax: 423-476-1673
Mailing address:
  • Phone: 423-476-7212
  • Fax: 423-476-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOHNATHAN PAUL CISCO
Title or Position: OWNER
Credential: OWNER
Phone: 423-476-7212