=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568815744
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REHAB TECHNOLOGY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2016
-----------------------------------------------------
Last Update Date | 08/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1890 GOODMAN RD E
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-9504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-269-0420
-----------------------------------------------------
Fax | 662-589-6525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1890 GOODMAN RD E
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-9504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-269-0420
-----------------------------------------------------
Fax | 662-589-6525
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | INDRAKSHI DUBEY
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 662-269-0420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | ST3991
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT0732
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | TA3236
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------