Provider Demographics
NPI:1215396890
Name:PEARSON, CALEB (DPT)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 ROY MARTIN RD STE 9
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2245
Mailing Address - Country:US
Mailing Address - Phone:423-477-1011
Mailing Address - Fax:423-477-1102
Practice Address - Street 1:110 E CENTER ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4230
Practice Address - Country:US
Practice Address - Phone:423-765-1611
Practice Address - Fax:423-765-1612
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-11
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TN10746261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6066842OtherBLUE CROSS BLUE SHIELD TN
TN10746OtherTN BOARD OF PT
TNQ022042Medicaid