=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003149030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CYPRESS THERAPY AND REHABILITATION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2009
-----------------------------------------------------
Last Update Date | 09/09/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RR 3 BOX 46
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62016-9506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-556-1225
-----------------------------------------------------
Fax | 214-942-3717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RR 3 BOX 46 P.O. BOX 45
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62016-9506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-556-1225
-----------------------------------------------------
Fax | 214-942-3717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. KATHY J. HEINZ-NEWINGHAM
-----------------------------------------------------
Credential | MS CCC/SLP
-----------------------------------------------------
Telephone | 217-556-1225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 146005569
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------