=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235642166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE PEDIATRIC THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2017
-----------------------------------------------------
Last Update Date | 11/14/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3315 SPRINGBANK LN STE 206
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-3198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-301-2894
-----------------------------------------------------
Fax | 704-970-0987
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12324 DANBY RD
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28134-6368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-301-2895
-----------------------------------------------------
Fax | 704-970-0987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST, OWNER
-----------------------------------------------------
Name | COURTNEY SCHULER
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 704-301-2895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 170
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------