Healthcare Provider Details

I. General information

NPI: 1508097734
Provider Name (Legal Business Name): THERA-PLAY PEDIATRIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 WOODLAWN DR
WILLIAMSTON NC
27892-1756
US

IV. Provider business mailing address

201 WOODLAWN DR
WILLIAMSTON NC
27892-1756
US

V. Phone/Fax

Practice location:
  • Phone: 252-809-9389
  • Fax: 252-792-1002
Mailing address:
  • Phone: 252-809-9389
  • Fax: 252-792-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1719
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number1719
License Number StateNC

VIII. Authorized Official

Name: KIMBERLY ROBERSON STEVENS
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTR/L
Phone: 252-809-9389