Healthcare Provider Details

I. General information

NPI: 1750626917
Provider Name (Legal Business Name): PEDIATRIC THERAPLAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3214 NODA BLVD
CHARLOTTE NC
28205-1259
US

IV. Provider business mailing address

3214 NODA BLVD
CHARLOTTE NC
28205-1259
US

V. Phone/Fax

Practice location:
  • Phone: 829-773-3038
  • Fax:
Mailing address:
  • Phone: 829-773-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number8042
License Number StateNC

VIII. Authorized Official

Name: WENDY TEAL
Title or Position: SLP
Credential:
Phone: 704-258-1724