Provider Demographics
NPI:1205099934
Name:PEDIATRIC THERAPY SERVICE
Entity type:Organization
Organization Name:PEDIATRIC THERAPY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:K
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:901-292-5313
Mailing Address - Street 1:11315 MCCORMICK RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38002-9512
Mailing Address - Country:US
Mailing Address - Phone:901-292-5313
Mailing Address - Fax:
Practice Address - Street 1:11315 MCCORMICK RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38002-9512
Practice Address - Country:US
Practice Address - Phone:901-292-5313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT42922251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08602897Medicaid