Healthcare Provider Details

I. General information

NPI: 1124086822
Provider Name (Legal Business Name): ABC PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 OLD WAREHOUSE SQ
OXFORD NC
27565-2957
US

IV. Provider business mailing address

1010 BROOKS BAY DR
ERIE PA
16505-5706
US

V. Phone/Fax

Practice location:
  • Phone: 919-693-1671
  • Fax:
Mailing address:
  • Phone: 252-213-0001
  • Fax: 919-693-9381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLI BENTSEN
Title or Position: MANAGER
Credential: PT
Phone: 919-693-1671