Provider Demographics
NPI:1053172783
Name:BLUFFTON CRANIOSACRAL & TONGUE TIE THERAPY, LLC
Entity type:Organization
Organization Name:BLUFFTON CRANIOSACRAL & TONGUE TIE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:631-897-7038
Mailing Address - Street 1:172 FLATWATER DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-9348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:172 FLATWATER DR
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-9348
Practice Address - Country:US
Practice Address - Phone:631-897-7038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty