Provider Demographics
NPI:1114233590
Name:PEDIATRIC BOULEVARD, PLLC
Entity Type:Organization
Organization Name:PEDIATRIC BOULEVARD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOINETTE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:LAGUERRE
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:704-821-0568
Mailing Address - Street 1:2814 GRAY FOX RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8422
Mailing Address - Country:US
Mailing Address - Phone:704-821-0568
Mailing Address - Fax:704-821-0570
Practice Address - Street 1:2814 GRAY FOX RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8422
Practice Address - Country:US
Practice Address - Phone:704-821-0568
Practice Address - Fax:704-821-0570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200741Medicaid