Provider Demographics
NPI:1104438076
Name:FUNCTIONAL STABILITY & MOBILITY LLC
Entity type:Organization
Organization Name:FUNCTIONAL STABILITY & MOBILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:HUTCHINSON FRAZIER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:609-354-8883
Mailing Address - Street 1:2112 MILES ST
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-4144
Mailing Address - Country:US
Mailing Address - Phone:254-290-3333
Mailing Address - Fax:254-300-9246
Practice Address - Street 1:2112 MILES ST
Practice Address - Street 2:
Practice Address - City:COPPERAS COVE
Practice Address - State:TX
Practice Address - Zip Code:76522-4144
Practice Address - Country:US
Practice Address - Phone:254-290-3333
Practice Address - Fax:254-300-9246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XR0403XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistDriving and Community MobilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX803010081OtherCERTIFICATE OF FILING NUMBER