=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962069286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEAP CHILD & FAMILY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2019
-----------------------------------------------------
Last Update Date | 05/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 NORTH TRADD STREET
-----------------------------------------------------
City | STATESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-330-2504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 34
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-500-9511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SATONYA D SMYRE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-330-2504
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 222Q00000X
-----------------------------------------------------
Taxonomy Name | Developmental Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------