Provider Demographics
NPI:1770209397
Name:HOMEGROWN PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:HOMEGROWN PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:843-432-6791
Mailing Address - Street 1:1428 CRAB APPLE LN
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-8258
Mailing Address - Country:US
Mailing Address - Phone:843-432-6791
Mailing Address - Fax:888-388-0830
Practice Address - Street 1:1428 CRAB APPLE LN
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-8258
Practice Address - Country:US
Practice Address - Phone:843-432-6791
Practice Address - Fax:888-388-0830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty