MEDICARE: SPECTRUM THERAPY SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103K00000X	Behavior Analyst
2	104100000X	Social Worker
3	133V00000X	Registered Dietitian
4	225800000X	Recreation Therapist
5	235Z00000X	Speech-Language Pathologist
6	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1134943392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM THERAPY SERVICES

Provider Business Mailing Address
First Line	:	1825 BLACKWOOD DR
Second Line	:
City	:	MAIDENS
State	:	VA
Zip	:	23102-2526
Country	:	US
Telephone Number	:	804-205-0355
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 BLACKWOOD DR
Second Line	:
City	:	MAIDENS
State	:	VA
Zip	:	23102-2526
Country	:	US
Telephone Number	:	804-205-0355
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NIKKI D STOUT
Credential	:	OTR
Telephone Number	:	804-205-0355

Provider Enumeration Date	:	11/13/2024
Last Update Date	:	11/19/2024

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