Provider Demographics
NPI:1255472403
Name:FULL SPECTRUM PEDIATRIC THERAPY, INC.
Entity Type:Organization
Organization Name:FULL SPECTRUM PEDIATRIC THERAPY, INC.
Other - Org Name:FULL SPECTRUM REHAB CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:KAREEN
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:931-906-0440
Mailing Address - Street 1:298 WARFIELD BLVD, SUITE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1896
Mailing Address - Country:US
Mailing Address - Phone:931-906-0440
Mailing Address - Fax:931-920-5070
Practice Address - Street 1:298 WARFIELD BLVD, SUITE C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-1896
Practice Address - Country:US
Practice Address - Phone:931-906-0440
Practice Address - Fax:931-920-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT 6520225100000X
TNOT 2156225X00000X
TNOT 2753225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4004828OtherTENNCARE PROVIDER NUMBER
TN4004828OtherBCBS PROVIDER NUMBER
TN4004828OtherTENNCARE PROVIDER NUMBER
TN446659Medicare ID - Type UnspecifiedOUTPATIENT REHAB