MEDICARE: FUNCTIONAL 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	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1184388654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL THERAPY

Provider Business Mailing Address
First Line	:	159 GRANBY CIR
Second Line	:
City	:	BEAVER
State	:	WV
Zip	:	25813-9233
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	159 GRANBY CIR
Second Line	:
City	:	BEAVER
State	:	WV
Zip	:	25813-9233
Country	:	US
Telephone Number	:	304-787-6348
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	TIFFANY BAILEY
Credential	:
Telephone Number	:	304-787-6348

Provider Enumeration Date	:	10/29/2021
Last Update Date	:	10/29/2021

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Directions to “FUNCTIONAL THERAPY ” Practice Location

Language	Start Address	Practice Location

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