Healthcare Provider Details

I. General information

NPI: 1922146877
Provider Name (Legal Business Name): EASTER SEALS UCP NORTH CAROLINA & VIRGINIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10510 MALLARD CREEK ROAD SUITE 510
CHARLOTTE NC
28262
US

IV. Provider business mailing address

5171 GLENWOOD AVE SUITE 400
RALEIGH NC
27612-3266
US

V. Phone/Fax

Practice location:
  • Phone: 704-333-8220
  • Fax: 704-333-7066
Mailing address:
  • Phone: 919-783-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: JELORE LITTLE
Title or Position: DIR, CONTRACTS & CREDENTIALING
Credential:
Phone: 336-545-6338