Healthcare Provider Details

I. General information

NPI: 1710585823
Provider Name (Legal Business Name): PURPOSEFUL PLAY PEDIATRIC THERAPY SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

657 SELF HOLLOW RD
ROCKFORD TN
37853
US

IV. Provider business mailing address

103 S PINE ST
MARYVILLE TN
37804-5102
US

V. Phone/Fax

Practice location:
  • Phone: 865-963-5569
  • Fax:
Mailing address:
  • Phone: 815-793-6009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE PRACH
Title or Position: SLP/OWNER
Credential: MS, CCC-SLP
Phone: 865-963-5569