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 |
