Provider Demographics
NPI:1053477265
Name:ABC PEDIATRIC THERAPY SERVICES, INC.
Entity Type:Organization
Organization Name:ABC PEDIATRIC THERAPY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:EAGER-KESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:404-556-5554
Mailing Address - Street 1:2655 DALLAS HWY SW
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2597
Mailing Address - Country:US
Mailing Address - Phone:404-556-5554
Mailing Address - Fax:770-428-2112
Practice Address - Street 1:2655 DALLAS HWY SW
Practice Address - Street 2:SUITE 320
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:404-556-5554
Practice Address - Fax:770-428-2112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00609056HMedicaid