Provider Demographics
NPI:1801218797
Name:NANTUCKET THERAPY, LLC
Entity Type:Organization
Organization Name:NANTUCKET THERAPY, LLC
Other - Org Name:NANTUCKET THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARYNNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:508-648-8348
Mailing Address - Street 1:125 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-4028
Mailing Address - Country:US
Mailing Address - Phone:508-648-8348
Mailing Address - Fax:508-796-6262
Practice Address - Street 1:125 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-4028
Practice Address - Country:US
Practice Address - Phone:508-648-8348
Practice Address - Fax:508-796-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-10
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8082235Z00000X
MA8216261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110094575AMedicaid
MA0031240OtherPTAN