Provider Demographics
NPI:1376953786
Name:LYMPHEDEMA THERAPY SOURCE
Entity Type:Organization
Organization Name:LYMPHEDEMA THERAPY SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OT, CLT-LANA
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:OT, CLT-LANA
Authorized Official - Phone:214-422-8265
Mailing Address - Street 1:9400 N MACARTHUR BLVD # 124-446
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-4705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W ELDORADO PKWY STE 108
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-5382
Practice Address - Country:US
Practice Address - Phone:214-422-8265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-07
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111147225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty