Healthcare Provider Details

I. General information

NPI: 1215510680
Provider Name (Legal Business Name): KIDD'S CONNECT OT, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2457 FAIRVIEW FARM RD
ASHEBORO NC
27205-8633
US

IV. Provider business mailing address

2457 FAIRVIEW FARM RD
ASHEBORO NC
27205-8633
US

V. Phone/Fax

Practice location:
  • Phone: 336-870-7860
  • Fax: 336-458-9460
Mailing address:
  • Phone: 336-870-7860
  • Fax: 336-458-9460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: LESLIE MIZE KIDD
Title or Position: OCCUPATIONAL THERAPIST/LICENSED
Credential: OT/L
Phone: 336-870-7860