Provider Demographics
NPI:1275105488
Name:GREAT ADVENTURES THERAPY LLC
Entity Type:Organization
Organization Name:GREAT ADVENTURES THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARITI
Authorized Official - Middle Name:
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:615-516-1702
Mailing Address - Street 1:12854 PECOS RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-0884
Mailing Address - Country:US
Mailing Address - Phone:615-516-1702
Mailing Address - Fax:865-674-5447
Practice Address - Street 1:12854 PECOS RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-0884
Practice Address - Country:US
Practice Address - Phone:615-516-1702
Practice Address - Fax:865-674-5447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ152866Medicaid