Basic Information
| Provider Information | |||||||||
| NPI: | 1740505346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERACT PEDIATRIC THERAPY SERVICES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5603 W FRIENDLY AVE STE B | ||||||||
| Address2: | #274 | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274104252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367725499 | ||||||||
| FaxNumber: | 3367409099 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 W WENDOVER AVE | ||||||||
| Address2: | C | ||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274088124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367725499 | ||||||||
| FaxNumber: | 3367409099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2010 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | MAYBERRY | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
| AuthorizedOfficialMiddleName: | COLE | ||||||||
| AuthorizedOfficialTitleorPosition: | COOWNER | ||||||||
| AuthorizedOfficialTelephone: | 3367725499 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OT/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 4531 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X | 3223 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7200380 | 05 | NC | MEDICAID |