Provider Demographics
NPI:1518414234
Name:DOGWOOD DEVELOPMENTAL THERAPY
Entity Type:Organization
Organization Name:DOGWOOD DEVELOPMENTAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CCC-SLP
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:910-824-4394
Mailing Address - Street 1:441 MCPHEE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5129
Mailing Address - Country:US
Mailing Address - Phone:910-824-4394
Mailing Address - Fax:
Practice Address - Street 1:16525 US HIGHWAY 17 N
Practice Address - Street 2:#D
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-7440
Practice Address - Country:US
Practice Address - Phone:910-824-4394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-10
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8028235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty