Provider Demographics
NPI:1750657664
Name:PEDIATRIC PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:E
Authorized Official - Last Name:HICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:304-366-8395
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WV
Mailing Address - Zip Code:26566-0088
Mailing Address - Country:US
Mailing Address - Phone:304-367-0750
Mailing Address - Fax:
Practice Address - Street 1:RR 6 BOX 260-6E
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-9396
Practice Address - Country:US
Practice Address - Phone:304-367-0750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-25
Last Update Date:2012-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1046-0165252Y00000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No252Y00000XAgenciesEarly Intervention Provider Agency