Provider Demographics
NPI:1306460308
Name:PURPLE ARCH NEURO REHABILITATION, LLC
Entity type:Organization
Organization Name:PURPLE ARCH NEURO REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:LAURIE
Authorized Official - Last Name:SOUTHERN
Authorized Official - Suffix:JR
Authorized Official - Credentials:SLPD
Authorized Official - Phone:586-859-9607
Mailing Address - Street 1:53359 CHAMPLAIN ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-3739
Mailing Address - Country:US
Mailing Address - Phone:586-859-9607
Mailing Address - Fax:
Practice Address - Street 1:53359 CHAMPLAIN ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-3739
Practice Address - Country:US
Practice Address - Phone:586-859-9607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty