Provider Demographics
NPI: | 1629151832 |
---|---|
Name: | PROFESSIONAL EARLY INTERVENTION SERVICES, LLC |
Entity Type: | Organization |
Organization Name: | PROFESSIONAL EARLY INTERVENTION SERVICES, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CYNTHIA |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | CARROLL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MED |
Authorized Official - Phone: | 910-425-6282 |
Mailing Address - Street 1: | 1708A OWEN DR |
Mailing Address - Street 2: | |
Mailing Address - City: | FAYETTEVILLE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28304-3419 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-425-6282 |
Mailing Address - Fax: | 910-425-6554 |
Practice Address - Street 1: | 1708A OWEN DR |
Practice Address - Street 2: | |
Practice Address - City: | FAYETTEVILLE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28304-3419 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-425-6282 |
Practice Address - Fax: | 910-425-6554 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-10-23 |
Last Update Date: | 2022-04-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | |
No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Multi-Specialty | |
No | 103TB0200X | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | Group - Multi-Specialty |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
No | 252Y00000X | Agencies | Early Intervention Provider Agency | ||
No | 261QD1600X | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | |
No | 261QH0700X | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | |
No | 261QM0855X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | |
No | 261QP2000X | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 7212109 | Medicaid | |
NC | 8300047K | Other | PLAY THERAPY |