Provider Demographics
NPI:1164782074
Name:KIDZ THERAPY SPOT
Entity Type:Organization
Organization Name:KIDZ THERAPY SPOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLEEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:678-305-9200
Mailing Address - Street 1:3040 HIGHLANDS PKWY SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5176
Mailing Address - Country:US
Mailing Address - Phone:678-305-9200
Mailing Address - Fax:678-305-9201
Practice Address - Street 1:3040 HIGHLANDS PKWY SE
Practice Address - Street 2:SUITE B
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-5176
Practice Address - Country:US
Practice Address - Phone:678-305-9200
Practice Address - Fax:678-305-9201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty