Healthcare Provider Details

I. General information

NPI: 1609115062
Provider Name (Legal Business Name): KID STRIDES THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2013
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5746 ROLLING MEADOWS RD
RANDLEMAN NC
27317-7896
US

IV. Provider business mailing address

5746 ROLLING MEADOWS RD
RANDLEMAN NC
27317-7896
US

V. Phone/Fax

Practice location:
  • Phone: 336-963-2365
  • Fax:
Mailing address:
  • Phone: 336-963-2365
  • Fax: 336-217-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA BETH PEARCE
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 336-963-2365