Healthcare Provider Details

I. General information

NPI: 1073125662
Provider Name (Legal Business Name): REHAB AT YOUR SPACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 N QUAIL HOLLOW RD
MEMPHIS TN
38120-1420
US

IV. Provider business mailing address

6320 N QUAIL HOLLOW RD
MEMPHIS TN
38120-1420
US

V. Phone/Fax

Practice location:
  • Phone: 901-409-1017
  • Fax:
Mailing address:
  • Phone: 901-409-1017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNA A AUSTIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 901-409-1017