Provider Demographics
NPI:1013360601
Name:IMPACT THERAPY OF GEORGIA
Entity Type:Organization
Organization Name:IMPACT THERAPY OF GEORGIA
Other - Org Name:IMPACT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WENKEL
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:678-910-3940
Mailing Address - Street 1:107 GRAND VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2747
Mailing Address - Country:US
Mailing Address - Phone:678-910-3940
Mailing Address - Fax:404-464-0819
Practice Address - Street 1:524 S HOUSTON LAKE RD STE B300
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-9042
Practice Address - Country:US
Practice Address - Phone:678-910-3940
Practice Address - Fax:404-464-0819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty