Provider Demographics
NPI:1487006706
Name:SPROUT PEDIATRIC THERAPY SERVICES
Entity Type:Organization
Organization Name:SPROUT PEDIATRIC THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:VAN BRUGGEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS IN OT
Authorized Official - Phone:712-441-1710
Mailing Address - Street 1:4244 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-7406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3498 450TH ST
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:IA
Practice Address - Zip Code:51041-7506
Practice Address - Country:US
Practice Address - Phone:712-737-9065
Practice Address - Fax:712-737-9064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001958225X00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0170200Medicaid