Basic Information
| Provider Information | |||||||||
| NPI: | 1518674506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUNCTIONAL DIFFERENCE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9932 SWEET BASIL DR | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275874127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194807008 | ||||||||
| FaxNumber: | 9198828502 | ||||||||
| Practice Location | |||||||||
| Address1: | 851 S BECKFORD DR STE A | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275365910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194807008 | ||||||||
| FaxNumber: | 9198828502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2022 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCBRIDE | ||||||||
| AuthorizedOfficialFirstName: | BRITTNEY | ||||||||
| AuthorizedOfficialMiddleName: | TARA | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9194807008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, OTR/L | ||||||||
| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.