Provider Demographics
NPI:1659008027
Name:FAIRVIEW PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:FAIRVIEW PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:MOT, OTR/L
Authorized Official - Phone:615-582-2942
Mailing Address - Street 1:7716 HUDLOW CT
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:TN
Mailing Address - Zip Code:37062-7331
Mailing Address - Country:US
Mailing Address - Phone:615-582-2942
Mailing Address - Fax:
Practice Address - Street 1:2092 FAIRVIEW BLVD STE 103
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:TN
Practice Address - Zip Code:37062-6012
Practice Address - Country:US
Practice Address - Phone:629-250-9317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-04
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ004435Medicaid
TNQ031734Medicaid