Provider Demographics
NPI:1073873824
Name:'I CAN' PEDIATRIC THERAPIES, LLC
Entity Type:Organization
Organization Name:'I CAN' PEDIATRIC THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MS OTR/L
Authorized Official - Phone:336-262-2086
Mailing Address - Street 1:PO BOX 1024
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-1024
Mailing Address - Country:US
Mailing Address - Phone:336-667-1555
Mailing Address - Fax:336-667-2088
Practice Address - Street 1:697 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-9562
Practice Address - Country:US
Practice Address - Phone:336-667-1555
Practice Address - Fax:336-667-2088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6541225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200533Medicaid