Provider Demographics
NPI:1417092925
Name:CAROLINA CHILDREN'S THERAPY
Entity Type:Organization
Organization Name:CAROLINA CHILDREN'S THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:HALES
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:919-630-9040
Mailing Address - Street 1:8031 US BUS HWY 70 W
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-4807
Mailing Address - Country:US
Mailing Address - Phone:919-630-9040
Mailing Address - Fax:919-553-3836
Practice Address - Street 1:8031 US BUS HWY 70 W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-4807
Practice Address - Country:US
Practice Address - Phone:919-630-9040
Practice Address - Fax:919-553-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1468225XP0200X
NC3916235Z00000X
NC6445235Z00000X
NC5846235Z00000X
NC3429235Z00000X
NC8686235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7210782Medicaid
NC011NUOtherBCBS GROUP PROVIDER NUMBE