Basic Information
| Provider Information | |||||||||
| NPI: | 1831162643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OT4 KIDS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 587 | ||||||||
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| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272930587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362366546 | ||||||||
| FaxNumber: | 3362369546 | ||||||||
| Practice Location | |||||||||
| Address1: | 440 CENTRAL AVENUE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272922634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362366546 | ||||||||
| FaxNumber: | 3362369546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 03/05/2012 | ||||||||
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| AuthorizedOfficialLastName: | STEPHENS | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | FRYE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3362366546 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | OTR/L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1164 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | 8820 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | 0149 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7211679 | 05 | NC | MEDICAID | 68681 | 01 | NC | BCBSNC | OTHER |