Healthcare Provider Details

I. General information

NPI: 1508688805
Provider Name (Legal Business Name): COMPLEAT KIDZ PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 E MAIN STREET SUITE 1000
RICHMOND VA
23219-4623
US

IV. Provider business mailing address

PO BOX 749
BELMONT NC
28012-0749
US

V. Phone/Fax

Practice location:
  • Phone: 704-915-6193
  • Fax:
Mailing address:
  • Phone: 704-915-6193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical 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 TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DERRICK FICKLING
Title or Position: SENIOR PAYER RELATIONS MANAGER
Credential:
Phone: 888-580-6180