Healthcare Provider Details

I. General information

NPI: 1902289853
Provider Name (Legal Business Name): STIMULATE YOUR CHILD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11721 OAK ST
CHARLOTTE NC
28269-2318
US

IV. Provider business mailing address

11721 OAK ST
CHARLOTTE NC
28269-2318
US

V. Phone/Fax

Practice location:
  • Phone: 704-975-2840
  • Fax: 704-248-8370
Mailing address:
  • Phone: 704-975-2840
  • Fax: 704-248-8370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number7509
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: GEORGIANA CHEVALIER LUKE-HENRY
Title or Position: DIRECTOR
Credential: OTR/L
Phone: 704-975-2840