Healthcare Provider Details

I. General information

NPI: 1265807606
Provider Name (Legal Business Name): DOGWOOD PEDIATRIC THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8360 SIX FORKS RD STE 101
RALEIGH NC
27615-5087
US

IV. Provider business mailing address

6428 CAPE CHARLES DR
RALEIGH NC
27617-7641
US

V. Phone/Fax

Practice location:
  • Phone: 919-247-4551
  • Fax: 919-882-9569
Mailing address:
  • Phone: 919-247-4551
  • Fax: 919-882-9569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8473
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LORI HARE
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential:
Phone: 919-247-4551