MEDICARE: ELEVATION PEDIATRIC THERAPY, LLC

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1053182006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATION PEDIATRIC THERAPY, LLC

Provider Business Mailing Address
First Line	:	1201 N MARTIN LUTHER KING JR DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27101-3005
Country	:	US
Telephone Number	:	336-579-3560
Fax Number	:	336-579-3561

Provider Business Practice Location Address
First Line	:	4065 PREMIER DR
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-8143
Country	:	US
Telephone Number	:	336-579-3560
Fax Number	:	336-579-3561

Authorized Official
Title or Position	:	CEO
Name	:	MR. ANDREW DINKINS
Credential	:
Telephone Number	:	336-579-3560

Provider Enumeration Date	:	01/09/2024
Last Update Date	:	01/21/2026

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