MEDICARE: PEDIATRIC THERAPY CONNECTION, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1003375288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC THERAPY CONNECTION, PLLC

Provider Business Mailing Address
First Line	:	4160 PIEDMONT PKWY STE 101
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8174
Country	:	US
Telephone Number	:	336-601-8604
Fax Number	:

Provider Business Practice Location Address
First Line	:	4160 PIEDMONT PKWY STE 101
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8174
Country	:	US
Telephone Number	:	336-601-8604
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLY T KEETER
Credential	:
Telephone Number	:	336-601-8604

Provider Enumeration Date	:	03/18/2019
Last Update Date	:	03/18/2019

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