=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942019740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROWTH AND GRACE PEDIATRIC OCCUPATIONAL THERAPY, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2025
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 874 FIELDSTOWN CIR
-----------------------------------------------------
City | GARDENDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35071-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-969-1467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 19TH ST N STE 201
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35203-3219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-969-1467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANDREA RICHELLE REED
-----------------------------------------------------
Credential | MBA, MS, OTR/L
-----------------------------------------------------
Telephone | 703-969-1467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------