Provider Demographics
NPI:1417235490
Name:FUNCTIONAL THERAPY LLC
Entity Type:Organization
Organization Name:FUNCTIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:VOLLENWEIDER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:228-216-9996
Mailing Address - Street 1:7533 CROOKED STICK DR
Mailing Address - Street 2:
Mailing Address - City:DIAMONDHEAD
Mailing Address - State:MS
Mailing Address - Zip Code:39525-3895
Mailing Address - Country:US
Mailing Address - Phone:228-255-8031
Mailing Address - Fax:601-620-4117
Practice Address - Street 1:311 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3313
Practice Address - Country:US
Practice Address - Phone:601-799-4065
Practice Address - Fax:601-620-4117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1249225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01458505Medicaid