Provider Demographics
NPI:1659796860
Name:FUNDAMENTAL THERAPY LLC
Entity Type:Organization
Organization Name:FUNDAMENTAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:CARR
Authorized Official - Last Name:BRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:601-916-8329
Mailing Address - Street 1:20 NEWT MITCHELL RD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-9224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:2014-02-25
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT2316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05587048Medicaid