Provider Demographics
NPI:1790015535
Name:CHILDREN'S REHAB
Entity Type:Organization
Organization Name:CHILDREN'S REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROBERSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:662-418-0233
Mailing Address - Street 1:1108 DR MARTIN LUTHER KING JR DR W
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-8864
Mailing Address - Country:US
Mailing Address - Phone:662-418-0233
Mailing Address - Fax:662-338-5439
Practice Address - Street 1:501 HIGHWAY 12 W STE 150E
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3643
Practice Address - Country:US
Practice Address - Phone:662-418-0233
Practice Address - Fax:662-338-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 1706261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123291Medicaid