MEDICARE: CARDINAL PEDIATRIC PSYCHOLOGY 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	103TC2200X	Clinical Child & Adolescent Psychologist

General Provider Information

NPI Number	:	1649866062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARDINAL PEDIATRIC PSYCHOLOGY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 51291
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27717-1291
Country	:	US
Telephone Number	:	984-245-6867
Fax Number	:

Provider Business Practice Location Address
First Line	:	1428 GENERAL LEE AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28305-4875
Country	:	US
Telephone Number	:	984-245-6867
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST/OWNER
Name	:	PAGE EAKER
Credential	:	PHD
Telephone Number	:	984-245-6867

Provider Enumeration Date	:	12/20/2020
Last Update Date	:	12/20/2020

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