Healthcare Provider Details

I. General information

NPI: 1063042166
Provider Name (Legal Business Name): TULLAHOMA PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/20/2024
Certification Date: 01/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1282 TURKEY CREEK DR
TULLAHOMA TN
37388-4672
US

IV. Provider business mailing address

1282 TURKEY CREEK DR
TULLAHOMA TN
37388-4672
US

V. Phone/Fax

Practice location:
  • Phone: 931-581-9018
  • Fax: 931-623-6133
Mailing address:
  • Phone: 931-581-9018
  • Fax: 931-623-6133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LAURA M MILLER
Title or Position: OWNER
Credential:
Phone: 931-581-9018