Provider Demographics
NPI:1942286372
Name:PEDIATRIC THERAPLAY SPEECH SERVICES, INC.
Entity Type:Organization
Organization Name:PEDIATRIC THERAPLAY SPEECH SERVICES, INC.
Other - Org Name:PEDIATRIC THERAPLAY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:YOSHINO
Authorized Official - Last Name:TEAL
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:704-258-1724
Mailing Address - Street 1:PO BOX 480462
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-5320
Mailing Address - Country:US
Mailing Address - Phone:704-258-1724
Mailing Address - Fax:704-598-3024
Practice Address - Street 1:3403 LINDEN BERRY LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1300
Practice Address - Country:US
Practice Address - Phone:704-258-1724
Practice Address - Fax:704-598-3024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-18
Last Update Date:2007-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2251P0200X, 252Y00000X
225X00000X, 225XP0200X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211876Medicaid