Basic Information
| Provider Information | |||||||||
| NPI: | 1487692851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYMOND SPEECH & REHAB., P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 113 HILLCREST DR | ||||||||
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| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304020 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 113 HILLCREST DR | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273304020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197770240 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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| AuthorizedOfficialLastName: | DYMOND | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANANGER | ||||||||
| AuthorizedOfficialTelephone: | 9197770240 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 2251P0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7211931 | 05 | NC | MEDICAID |