=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720451453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AEGIS THERAPIES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2015
-----------------------------------------------------
Last Update Date | 03/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 WAVELAND AVE
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40391-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-823-8375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4933 OLD GREENWOOD RD
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72903-6906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-823-8375
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | HOLLY RASMUSSEN-JONES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-201-4835
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------