Healthcare Provider Details

I. General information

NPI: 1932086022
Provider Name (Legal Business Name): GRACE PEDIATRIC THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BECKER DR STE B
ROANOKE RAPIDS NC
27870-3165
US

IV. Provider business mailing address

400 BECKER DR STE B
ROANOKE RAPIDS NC
27870-3165
US

V. Phone/Fax

Practice location:
  • Phone: 252-578-1069
  • Fax:
Mailing address:
  • Phone: 252-578-1069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY ALLEN
Title or Position: OWNER
Credential:
Phone: 252-578-1069