Provider Demographics
NPI:1144568726
Name:KIDSPROUT THERAPY
Entity Type:Organization
Organization Name:KIDSPROUT THERAPY
Other - Org Name:KIDSPROUT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SAJINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-641-1803
Mailing Address - Street 1:10405 STALLION WAY
Mailing Address - Street 2:
Mailing Address - City:BAHAMA
Mailing Address - State:NC
Mailing Address - Zip Code:27503-9631
Mailing Address - Country:US
Mailing Address - Phone:919-641-1803
Mailing Address - Fax:919-287-2869
Practice Address - Street 1:10405 STALLION WAY
Practice Address - Street 2:
Practice Address - City:BAHAMA
Practice Address - State:NC
Practice Address - Zip Code:27503-9631
Practice Address - Country:US
Practice Address - Phone:919-641-1803
Practice Address - Fax:919-287-2869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-16
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200576Medicaid