=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427093749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLESTON CHILDREN'S THERAPY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2006
-----------------------------------------------------
Last Update Date | 11/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9225 UNIVERSITY BLVD STE. E2C
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-569-4546
-----------------------------------------------------
Fax | 843-569-4535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9225 UNIVERSITY BLVD STE. E2C
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-9149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-569-4546
-----------------------------------------------------
Fax | 843-569-4535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER/MANAGER
-----------------------------------------------------
Name | MS. CHARLENE DURHAM
-----------------------------------------------------
Credential | MSR, PT
-----------------------------------------------------
Telephone | 843-569-4546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------