Healthcare Provider Details

I. General information

NPI: 1639511835
Provider Name (Legal Business Name): CASA CARE PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17115 KENTON DR SUITE 204-A
CORNELIUS NC
28031-5645
US

IV. Provider business mailing address

17115 KENTON DR SUITE 204-A
CORNELIUS NC
28031-5645
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-8074
  • Fax: 704-892-8075
Mailing address:
  • Phone: 704-892-8074
  • Fax: 704-892-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberP11495
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number8676
License Number StateNC

VIII. Authorized Official

Name: KAREN L. CRILLY
Title or Position: OWNER/CLINIC DIRECTOR
Credential: PT, MAPT, DPT
Phone: 704-892-8074