=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891562914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC THERAPY WORKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2023
-----------------------------------------------------
Last Update Date | 12/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 MERRIMAN AVE E
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-270-7963
-----------------------------------------------------
Fax | 870-374-6061
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 COUNTY ROAD 7290
-----------------------------------------------------
City | WYNNE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72396-8121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-270-7963
-----------------------------------------------------
Fax | 870-374-6061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MS. JAMIE FREDERICK
-----------------------------------------------------
Credential | MCD, CCC-SLP
-----------------------------------------------------
Telephone | 870-270-7963
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------