Healthcare Provider Details

I. General information

NPI: 1780075952
Provider Name (Legal Business Name): ABC PLAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 HALSTEAD BLVD
ELIZABETH CITY NC
27909-5840
US

IV. Provider business mailing address

PO BOX 1614
ELIZABETH CITY NC
27906-1614
US

V. Phone/Fax

Practice location:
  • Phone: 252-333-8445
  • Fax: 252-404-9136
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNC

VIII. Authorized Official

Name: WILKIAM WILSON
Title or Position: IFTS, LCAS-A
Credential: BS, MS, ITFS, LCAS-A
Phone: 252-312-0516