Provider Demographics
NPI:1679987606
Name:FULL SPECTRUM PEDIATRIC THERAPY
Entity type:Organization
Organization Name:FULL SPECTRUM PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANA
Authorized Official - Middle Name:KAREEN
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:931-906-0440
Mailing Address - Street 1:298 WARFIELD BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1828
Mailing Address - Country:US
Mailing Address - Phone:931-906-0440
Mailing Address - Fax:
Practice Address - Street 1:298 WARFIELD BLVD STE C
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-1828
Practice Address - Country:US
Practice Address - Phone:931-906-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2324224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty