Provider Demographics
NPI:1760252571
Name:NEUROACTIVE THERAPY AND WELLNESS LLC
Entity Type:Organization
Organization Name:NEUROACTIVE THERAPY AND WELLNESS LLC
Other - Org Name:NEURORECOVERY PT LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:KACZMAREK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:941-539-4395
Mailing Address - Street 1:4500 CAHABA RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35216-6825
Mailing Address - Country:US
Mailing Address - Phone:941-539-4395
Mailing Address - Fax:
Practice Address - Street 1:4500 CAHABA RIVER BLVD
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35216-6825
Practice Address - Country:US
Practice Address - Phone:941-539-4395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-03
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty