Provider Demographics
NPI:1114262318
Name:SPROUT THERAPY GROUP - PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH
Entity Type:Organization
Organization Name:SPROUT THERAPY GROUP - PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH
Other - Org Name:SPROUT THERAPY GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DORFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-450-4898
Mailing Address - Street 1:108 SOUTHVIEW RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-2206
Mailing Address - Country:US
Mailing Address - Phone:315-450-4898
Mailing Address - Fax:315-834-4898
Practice Address - Street 1:108 SOUTHVIEW RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-2206
Practice Address - Country:US
Practice Address - Phone:315-450-4898
Practice Address - Fax:315-834-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency