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General NPI Number Information
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NPI Number | 1770060964
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Entity Type | Organization
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Legal Business Name | SPROUT PEDIATRIC THERAPY, LLC
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Dates
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Enumeration Date | 07/20/2018
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Last Update Date | 07/20/2018
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Provider Practice Location Address
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Address Line | 108 SERENITY WAY
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City | MADISON
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State | MS
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Zip | 39110-6992
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Country | US
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Telephone | 601-831-2360
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Fax | 601-510-9735
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Provider Business Mailing Address
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Address Line | 108 SERENITY WAY
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City | MADISON
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State | MS
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Zip | 39110-6992
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Country | US
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Telephone | 601-831-2360
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Fax | 601-510-9735
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | MRS. EMILY R CUSTER
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Credential | MS,PT
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Telephone | 601-831-2360
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT3255
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License Number State | MS
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