Healthcare Provider Details

I. General information

NPI: 1861081572
Provider Name (Legal Business Name): FLOYD PEDIATRIC THERAPY AND INTERVENTION FOR TIC DISORDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2021
Last Update Date: 01/16/2021
Certification Date: 01/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 S MOUNT JULIET RD
MOUNT JULIET TN
37122-6319
US

IV. Provider business mailing address

651 S MOUNT JULIET RD
MOUNT JULIET TN
37122-6319
US

V. Phone/Fax

Practice location:
  • Phone: 757-969-2300
  • Fax:
Mailing address:
  • Phone: 757-969-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ROBERT FOREMAN
Title or Position: BILLING
Credential:
Phone: 630-216-9437