Provider Demographics
NPI:1073630992
Name:PEACH STATE PEDIATRIC THERAPY INC.
Entity Type:Organization
Organization Name:PEACH STATE PEDIATRIC THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUNEYL
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:678-524-3451
Mailing Address - Street 1:457 AUTUMN PARK TRCE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7421
Mailing Address - Country:US
Mailing Address - Phone:678-524-3451
Mailing Address - Fax:770-921-7380
Practice Address - Street 1:457 AUTUMN PARK TRCE
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7421
Practice Address - Country:US
Practice Address - Phone:678-524-3451
Practice Address - Fax:770-921-7380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002948174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty