=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235856436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADAPTIVE TEAM THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2022
-----------------------------------------------------
Last Update Date | 10/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 N TYLER ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-413-9546
-----------------------------------------------------
Fax | 501-325-1315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3722 GRACEFUL OAKS DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72019-2028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-413-9546
-----------------------------------------------------
Fax | 501-325-1315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | RACHEL GLENN
-----------------------------------------------------
Credential | MS OTR/L
-----------------------------------------------------
Telephone | 501-413-9546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------