=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861081572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLOYD PEDIATRIC THERAPY AND INTERVENTION FOR TIC DISORDERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2021
-----------------------------------------------------
Last Update Date | 01/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 651 S MOUNT JULIET RD
-----------------------------------------------------
City | MOUNT JULIET
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37122-6319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-969-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 651 S MOUNT JULIET RD
-----------------------------------------------------
City | MOUNT JULIET
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37122-6319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-969-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING
-----------------------------------------------------
Name | ROBERT FOREMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-216-9437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------