Provider Demographics
NPI:1457788929
Name:MLPHENRYDBA DEVELOPMENTAL THERAPY SERVICES
Entity Type:Organization
Organization Name:MLPHENRYDBA DEVELOPMENTAL THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CBRS PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET LISA
Authorized Official - Middle Name:PIKE
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-214-2879
Mailing Address - Street 1:7125 BASS MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SNOW CAMP
Mailing Address - State:NC
Mailing Address - Zip Code:27349-9167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7125 BASS MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SNOW CAMP
Practice Address - State:NC
Practice Address - Zip Code:27349-9167
Practice Address - Country:US
Practice Address - Phone:336-214-2879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCBRS INFANT TODDLER251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300168KMedicaid
NC8300168Medicaid
NC1417091034OtherNPI- INDIVIDUAL