Provider Demographics
NPI:1013426980
Name:INTEGRATED PEDIATRIC THERAPIES
Entity Type:Organization
Organization Name:INTEGRATED PEDIATRIC THERAPIES
Other - Org Name:KIDS AT PLAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-217-9366
Mailing Address - Street 1:1222 MATTEO DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2010
Mailing Address - Country:US
Mailing Address - Phone:203-217-9366
Mailing Address - Fax:
Practice Address - Street 1:1222 MATTEO DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2010
Practice Address - Country:US
Practice Address - Phone:203-217-9366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATED PEDIATRIC THERAPIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9721251E00000X
CT1758251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health