=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548576382
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TINY TOTS THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2010
-----------------------------------------------------
Last Update Date | 08/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RR 2 BOX 154B
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62565-8237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-412-0616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | RR 2 BOX 154B
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62565-8237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | MS. CORRIN REIMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-412-0616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 146010364
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------