Provider Demographics
NPI:1063021715
Name:MITTEN STATE PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:MITTEN STATE PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMMAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-535-4666
Mailing Address - Street 1:6659 CRAFTSMAN SQUARE DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8861
Mailing Address - Country:US
Mailing Address - Phone:248-535-4666
Mailing Address - Fax:
Practice Address - Street 1:5258 PLAINFIELD AVE NE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1092
Practice Address - Country:US
Practice Address - Phone:616-466-4068
Practice Address - Fax:616-369-1646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty