Provider Demographics
NPI:1710183991
Name:PEDIATRIC DEVELOPMENTAL THERAPY
Entity Type:Organization
Organization Name:PEDIATRIC DEVELOPMENTAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HADEN
Authorized Official - Middle Name:PAYNE
Authorized Official - Last Name:BOLIEK
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:910-483-8331
Mailing Address - Street 1:PO BOX 87294
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7294
Mailing Address - Country:US
Mailing Address - Phone:910-483-8331
Mailing Address - Fax:910-483-8335
Practice Address - Street 1:1289 OLIVER ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4450
Practice Address - Country:US
Practice Address - Phone:910-483-8331
Practice Address - Fax:910-483-8335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC225400000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301184Medicaid