Provider Demographics
NPI:1053586685
Name:PEDIATRIC THERAPY GROUP LLC
Entity type:Organization
Organization Name:PEDIATRIC THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:MOREE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:225-921-7216
Mailing Address - Street 1:1034 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70815-4509
Mailing Address - Country:US
Mailing Address - Phone:225-921-7216
Mailing Address - Fax:225-927-4059
Practice Address - Street 1:1034 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-4509
Practice Address - Country:US
Practice Address - Phone:225-921-7216
Practice Address - Fax:225-927-4059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4906235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty