Provider Demographics
NPI:1376228320
Name:SPROUT THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:SPROUT THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:REISHUS
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:218-371-6647
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:VERGAS
Mailing Address - State:MN
Mailing Address - Zip Code:56587-0193
Mailing Address - Country:US
Mailing Address - Phone:218-234-2094
Mailing Address - Fax:888-892-2924
Practice Address - Street 1:50438 W LAKE SEVEN RD
Practice Address - Street 2:
Practice Address - City:FRAZEE
Practice Address - State:MN
Practice Address - Zip Code:56544-8919
Practice Address - Country:US
Practice Address - Phone:218-234-2094
Practice Address - Fax:888-892-2924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty