Provider Demographics
NPI:1396903209
Name:SPECIALIZED THERAPY SERVICES, LLC
Entity type:Organization
Organization Name:SPECIALIZED THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-296-9191
Mailing Address - Street 1:16 OFFICE PARK DR
Mailing Address - Street 2:SUITE 21
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-6020
Mailing Address - Country:US
Mailing Address - Phone:601-296-9191
Mailing Address - Fax:601-296-9190
Practice Address - Street 1:16 OFFICE PARK DR
Practice Address - Street 2:SUITE 21
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-6020
Practice Address - Country:US
Practice Address - Phone:601-296-9191
Practice Address - Fax:601-296-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0932225100000X
MSOT0493225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS587471053AOtherBLUE CROSS BLUE SHIELD
MSP00062876OtherMEDICARE RAILROAD
MS03389700Medicaid
MS670000041OtherMEDICARE