Provider Demographics
NPI:1427196906
Name:PEDIATRIC PLAY THERAPY, LLC
Entity Type:Organization
Organization Name:PEDIATRIC PLAY THERAPY, LLC
Other - Org Name:PEDIATRIC PLAY THERAPY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:CHARMAINE
Authorized Official - Last Name:BELLGRANTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-736-8580
Mailing Address - Street 1:1709 TOMMYS RD
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7991
Mailing Address - Country:US
Mailing Address - Phone:919-736-8580
Mailing Address - Fax:
Practice Address - Street 1:1709 TOMMYS RD
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-7991
Practice Address - Country:US
Practice Address - Phone:919-736-8580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300049Medicaid