=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821778713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABC PEDIATRIC THERAPY OF MISSISSIPPI, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2023
-----------------------------------------------------
Last Update Date | 01/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1130 STATELINE RD E STE D-E
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-536-6884
-----------------------------------------------------
Fax | 662-510-5892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1130 STATELINE RD E STE D-E
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-8700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-536-6884
-----------------------------------------------------
Fax | 662-510-5892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | JESSICA WHALUM
-----------------------------------------------------
Credential | OTD, OTR/L
-----------------------------------------------------
Telephone | 662-536-6884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------