Basic Information
| Provider Information | |||||||||
| NPI: | 1326588625 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GROWING WISE THERAPY SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 159 THELMA CIR | ||||||||
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| City: | JACKSBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377574832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234948398 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10721 CHAPMAN HWY STE 27 | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378654767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234948398 | ||||||||
| FaxNumber: | 8652462106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2017 | ||||||||
| LastUpdateDate: | 12/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | ASBURY | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 4234948398 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5309 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.