Provider Demographics
NPI:1275984114
Name:FUNWORKS PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:FUNWORKS PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:910-689-5071
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:MINFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45653-0022
Mailing Address - Country:US
Mailing Address - Phone:910-689-5071
Mailing Address - Fax:888-398-8146
Practice Address - Street 1:408 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-9660
Practice Address - Country:US
Practice Address - Phone:910-689-5071
Practice Address - Fax:888-398-8146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY003960252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency