Provider Demographics
NPI:1073991964
Name:HULLABALOO PEDIATRIC THERAPY PLLC
Entity Type:Organization
Organization Name:HULLABALOO PEDIATRIC THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRIMSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:903-391-8170
Mailing Address - Street 1:311 GLENWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801
Mailing Address - Country:US
Mailing Address - Phone:903-391-8170
Mailing Address - Fax:
Practice Address - Street 1:2035 CROCKETT RD
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-5921
Practice Address - Country:US
Practice Address - Phone:903-723-3602
Practice Address - Fax:903-731-9573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX108561261QH0700X
TX1099075261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX108015203Medicaid
TX201775804Medicaid
TX351507401Medicaid
TX351990201Medicaid