MEDICARE: SPARROW KIDS PEDIATRIC THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist

General Provider Information

NPI Number	:	1043073182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPARROW KIDS PEDIATRIC THERAPY

Provider Business Mailing Address
First Line	:	257 LONG RANGER RD
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79602-1531
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	257 LONG RANGER RD
Second Line	:
City	:	ABILENE
State	:	TX
Zip	:	79602-1531
Country	:	US
Telephone Number	:	325-232-1023
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	MICHELLE CAMPODONICO
Credential	:	OTR
Telephone Number	:	325-232-1023

Provider Enumeration Date	:	02/01/2024
Last Update Date	:	02/01/2024

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