Provider Demographics
NPI:1033315734
Name:THERA-PEDS
Entity Type:Organization
Organization Name:THERA-PEDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR L
Authorized Official - Phone:919-739-0047
Mailing Address - Street 1:PO BOX 10723
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27532-0723
Mailing Address - Country:US
Mailing Address - Phone:919-739-0047
Mailing Address - Fax:191-739-0041
Practice Address - Street 1:1214 PARKWAY DRIVE
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-3448
Practice Address - Country:US
Practice Address - Phone:919-739-0047
Practice Address - Fax:919-739-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005202Medicaid