Healthcare Provider Details

I. General information

NPI: 1730137779
Provider Name (Legal Business Name): PEDIATRIC DEVELOPMENTAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 OLIVER ST
FAYETTEVILLE NC
28304-4450
US

IV. Provider business mailing address

PO BOX 87294
FAYETTEVILLE NC
28304-7294
US

V. Phone/Fax

Practice location:
  • Phone: 910-483-8331
  • Fax: 910-483-8335
Mailing address:
  • Phone: 910-483-8331
  • Fax: 910-483-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: HADEN PAYNE BOLIEK
Title or Position: PRESIDENT
Credential: MSCCCSLP
Phone: 910-483-8331