Provider Demographics
NPI:1821480344
Name:PROCARE THERAPY
Entity Type:Organization
Organization Name:PROCARE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLPA
Authorized Official - Prefix:
Authorized Official - First Name:KANOUSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTON-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-303-3102
Mailing Address - Street 1:303 PORTER DR
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-3717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 N EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-3313
Practice Address - Country:US
Practice Address - Phone:785-717-9340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency