Provider Demographics
NPI:1780049429
Name:PTA
Entity type:Organization
Organization Name:PTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:
Authorized Official - First Name:HRACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AYUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-609-1832
Mailing Address - Street 1:1900 SHELDON RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-1645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 SHELDON ROAD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405
Practice Address - Country:US
Practice Address - Phone:336-609-1832
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2251500000X320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities