Provider Demographics
NPI:1922619667
Name:MOUNTAIN CITY PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:MOUNTAIN CITY PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-218-9729
Mailing Address - Street 1:146 CALVARY LANE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37683
Mailing Address - Country:US
Mailing Address - Phone:423-218-9729
Mailing Address - Fax:423-727-0730
Practice Address - Street 1:146 CALVARY LANE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683
Practice Address - Country:US
Practice Address - Phone:423-218-9729
Practice Address - Fax:423-727-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-15
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty