Provider Demographics
NPI:1578005849
Name:STIMULATE YOUR CHILD DEVELOPMENTAL THERAPY PLLC
Entity Type:Organization
Organization Name:STIMULATE YOUR CHILD DEVELOPMENTAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GEORGIANA
Authorized Official - Middle Name:C
Authorized Official - Last Name:LUKE-HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:704-975-2840
Mailing Address - Street 1:1646 RUSTIC ARCH WAY
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-3628
Mailing Address - Country:US
Mailing Address - Phone:704-975-2840
Mailing Address - Fax:704-998-8907
Practice Address - Street 1:1646 RUSTIC ARCH WAY
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3628
Practice Address - Country:US
Practice Address - Phone:704-975-2840
Practice Address - Fax:704-998-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7509225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302306Medicaid
NC1134276843OtherNPI