MEDICARE: LYMPHEDEMA THERAPY SOURCE

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	225X00000X	Occupational Therapist	111147	TX

General Provider Information

NPI Number	:	1376953786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYMPHEDEMA THERAPY SOURCE

Provider Business Mailing Address
First Line	:	9400 N MACARTHUR BLVD # 124-446
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-4705
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	309 W ELDORADO PKWY STE 108
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-5382
Country	:	US
Telephone Number	:	214-422-8265
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OT, CLT-LANA
Name	:	REBECCA SUMMERS
Credential	:	OT, CLT-LANA
Telephone Number	:	214-422-8265

Provider Enumeration Date	:	05/07/2014
Last Update Date	:	04/19/2024

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