Provider Demographics
NPI:1427093749
Name:CHARLESTON CHILDREN'S THERAPY CENTER, LLC
Entity type:Organization
Organization Name:CHARLESTON CHILDREN'S THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MSR, PT
Authorized Official - Phone:843-569-4546
Mailing Address - Street 1:9225 UNIVERSITY BLVD
Mailing Address - Street 2:STE. E2C
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9149
Mailing Address - Country:US
Mailing Address - Phone:843-569-4546
Mailing Address - Fax:843-569-4535
Practice Address - Street 1:9225 UNIVERSITY BLVD
Practice Address - Street 2:STE. E2C
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9149
Practice Address - Country:US
Practice Address - Phone:843-569-4546
Practice Address - Fax:843-569-4535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3928Medicaid