Basic Information
| Provider Information | |||||||||
| NPI: | 1538394424 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE SPORTS THERAPY, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3026 HIDDEN LAKE PT | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423034455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706859499 | ||||||||
| FaxNumber: | 2706859443 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 SCHERM RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423015300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706859499 | ||||||||
| FaxNumber: | 2706859443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2009 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | PHELPS | ||||||||
| AuthorizedOfficialFirstName: | TRISHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2706859499 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.T | ||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | 31001124A | IN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 208100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.