Provider Demographics
NPI:1821778713
Name:ABC PEDIATRIC THERAPY OF MISSISSIPPI, LLC
Entity Type:Organization
Organization Name:ABC PEDIATRIC THERAPY OF MISSISSIPPI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHALUM
Authorized Official - Suffix:
Authorized Official - Credentials:OTD, OTR/L
Authorized Official - Phone:662-536-6884
Mailing Address - Street 1:1130 STATELINE RD E STE D-E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-8700
Mailing Address - Country:US
Mailing Address - Phone:662-536-6884
Mailing Address - Fax:662-510-5892
Practice Address - Street 1:1130 STATELINE RD E STE D-E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-8700
Practice Address - Country:US
Practice Address - Phone:662-536-6884
Practice Address - Fax:662-510-5892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-24
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation