Provider Demographics
NPI:1346647799
Name:PEDIATRIC THERAPEUTIC COACHING
Entity Type:Organization
Organization Name:PEDIATRIC THERAPEUTIC COACHING
Other - Org Name:PEDIATRIC THERAPEUTIC COACHING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH/LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC SLP
Authorized Official - Phone:704-787-0224
Mailing Address - Street 1:1171 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6500
Mailing Address - Country:US
Mailing Address - Phone:704-787-0224
Mailing Address - Fax:
Practice Address - Street 1:1301 ROLLING HILLS CT
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-9148
Practice Address - Country:US
Practice Address - Phone:704-787-0224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5556235Z00000X
NC7056235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346204708OtherNPI