MEDICARE: DEVELOPMENTAL THERAPY OUTREACH SERVICES

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225222896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVELOPMENTAL THERAPY OUTREACH SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 11928
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27703-1928
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4506 TYNE DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27703-2891
Country	:	US
Telephone Number	:	919-596-5047
Fax Number	:

Authorized Official
Title or Position	:	BILLING
Name	:	SAJINA COOPER
Credential	:
Telephone Number	:	919-381-1112

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	08/28/2007

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