Provider Demographics
NPI:1013426980
Name:INTEGRATED PEDIATRIC THERAPIES
Entity type:Organization
Organization Name:INTEGRATED PEDIATRIC THERAPIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WICKLINE
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:203-217-9366
Mailing Address - Street 1:3260 OCEANIC BAY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-6401
Mailing Address - Country:US
Mailing Address - Phone:203-217-9366
Mailing Address - Fax:910-393-9749
Practice Address - Street 1:138 MEMORY PLZ
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-2640
Practice Address - Country:US
Practice Address - Phone:910-393-9749
Practice Address - Fax:910-250-1244
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:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9721251E00000X
CT1758251E00000X
208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty