Provider Demographics
NPI:1730137779
Name:PEDIATRIC DEVELOPMENTAL THERAPY
Entity Type:Organization
Organization Name:PEDIATRIC DEVELOPMENTAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HADEN
Authorized Official - Middle Name:PAYNE
Authorized Official - Last Name:BOLIEK
Authorized Official - Suffix:
Authorized Official - Credentials:MSCCCSLP
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:2006-05-04
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7210315Medicaid