Provider Demographics
NPI:1871862003
Name:RECONNECT THERAPY
Entity Type:Organization
Organization Name:RECONNECT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KAVANAGH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:251-605-4669
Mailing Address - Street 1:1410 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1129
Mailing Address - Country:US
Mailing Address - Phone:662-423-3422
Mailing Address - Fax:662-423-5259
Practice Address - Street 1:1410 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1129
Practice Address - Country:US
Practice Address - Phone:662-423-3422
Practice Address - Fax:662-423-5259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12072634314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility