Healthcare Provider Details

I. General information

NPI: 1114229036
Provider Name (Legal Business Name): SPECIALIZED INNOVATIVE THERAPIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 12/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14124 ASTON FALLS DR
HASLET TX
76052-2408
US

IV. Provider business mailing address

14124 ASTON FALLS DR
HASLET TX
76052-2408
US

V. Phone/Fax

Practice location:
  • Phone: 817-454-9930
  • Fax: 817-439-5274
Mailing address:
  • Phone: 817-454-9930
  • Fax: 817-439-5274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number09005
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. TOREY RASBERRY
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 850-319-3149