Provider Demographics
NPI:1821535857
Name:DISCOVERY PEDIATRIC PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:DISCOVERY PEDIATRIC PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEVEREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT, CLT
Authorized Official - Phone:704-778-6338
Mailing Address - Street 1:2233 WEDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-9254
Mailing Address - Country:US
Mailing Address - Phone:704-778-6338
Mailing Address - Fax:704-973-0068
Practice Address - Street 1:2233 WEDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-9254
Practice Address - Country:US
Practice Address - Phone:704-778-6338
Practice Address - Fax:704-973-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-29
Last Update Date:2017-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty