Healthcare Provider Details

I. General information

NPI: 1033315734
Provider Name (Legal Business Name): THERA-PEDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 PARKWAY DRIVE
GOLDSBORO NC
27534-3448
US

IV. Provider business mailing address

PO BOX 10723
GOLDSBORO NC
27532-0723
US

V. Phone/Fax

Practice location:
  • Phone: 919-739-0047
  • Fax: 919-739-0041
Mailing address:
  • Phone: 919-739-0047
  • Fax: 191-739-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. MARJORIE PATE
Title or Position: OWNER
Credential: OTR L
Phone: 919-739-0047