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General NPI Number Information
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NPI Number | 1386036911
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Entity Type | Organization
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Legal Business Name | GRASSROOTS THERAPY SOLUTIONS LLC
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Dates
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Enumeration Date | 02/18/2015
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Last Update Date | 02/18/2015
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Provider Practice Location Address
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Address Line | 1057 MONROE ST
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City | JACKSON
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State | MS
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Zip | 39202-2730
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Country | US
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Telephone | 662-497-0485
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Fax |
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Provider Business Mailing Address
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Address Line | 1057 MONROE ST
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City | JACKSON
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State | MS
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Zip | 39202-2730
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEPHANIE MIMMS
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Credential | MOTR/L
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Telephone | 662-497-0485
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT2925
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License Number State | MS
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