Healthcare Provider Details

I. General information

NPI: 1205204500
Provider Name (Legal Business Name): INDEPENDENT PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 W BROADWAY AVE
MARYVILLE TN
37801-5402
US

IV. Provider business mailing address

8823 PRODUCTION LN
OOLTEWAH TN
37363-6511
US

V. Phone/Fax

Practice location:
  • Phone: 865-983-8129
  • Fax: 865-983-8293
Mailing address:
  • Phone: 423-238-7217
  • Fax: 423-238-3417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KEVIN JOHANNESON
Title or Position: VP REVENUE CYCLE
Credential:
Phone: 423-238-8923