Provider Demographics
NPI:1831720820
Name:THE KID GURU, LLC
Entity type:Organization
Organization Name:THE KID GURU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:704-705-5202
Mailing Address - Street 1:6852 LANDOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28152
Mailing Address - Country:US
Mailing Address - Phone:704-705-5202
Mailing Address - Fax:
Practice Address - Street 1:6852 LANDOR DRIVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28152
Practice Address - Country:US
Practice Address - Phone:704-705-5202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Yes251S00000XAgenciesCommunity/Behavioral Health