Provider Demographics
NPI:1124086822
Name:ABC PEDIATRIC THERAPY, LLC
Entity type:Organization
Organization Name:ABC PEDIATRIC THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:919-693-1671
Mailing Address - Street 1:1010 BROOKS BAY DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-5706
Mailing Address - Country:US
Mailing Address - Phone:252-213-0001
Mailing Address - Fax:919-693-9381
Practice Address - Street 1:153 OLD WAREHOUSE SQ
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2957
Practice Address - Country:US
Practice Address - Phone:919-693-1671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102970525002Medicaid
NC8300020Medicaid
NC013P7OtherBCBS GROUP NUMBER
NC7211211Medicaid