Provider Demographics
NPI:1225496284
Name:PEACH STATE PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:PEACH STATE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KUNEYL
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:770-904-6419
Mailing Address - Street 1:4992 BRISTOL INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1742
Mailing Address - Country:US
Mailing Address - Phone:770-904-6419
Mailing Address - Fax:770-904-6418
Practice Address - Street 1:4992 BRISTOL INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1742
Practice Address - Country:US
Practice Address - Phone:770-904-6419
Practice Address - Fax:770-904-6418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004775225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty