Basic Information
| Provider Information | |||||||||
| NPI: | 1508849332 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATIVE THERAPY CONCEPTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 INFIELD COURT | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047996824 | ||||||||
| FaxNumber: | 7047996825 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 INFIELD RD | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281178026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047996824 | ||||||||
| FaxNumber: | 7047996825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| AuthorizedOfficialLastName: | GIANOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER OTRL | ||||||||
| AuthorizedOfficialTelephone: | 7047996824 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTRL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7210778 | 05 | NC | MEDICAID |