Provider Demographics
NPI:1245796424
Name:BSTSA INC DBA SPECTRUM THERAPY CENTER
Entity Type:Organization
Organization Name:BSTSA INC DBA SPECTRUM THERAPY CENTER
Other - Org Name:SPECTRUM THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-609-6789
Mailing Address - Street 1:1373 CHLOE DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8383
Mailing Address - Country:US
Mailing Address - Phone:843-655-3731
Mailing Address - Fax:
Practice Address - Street 1:2346 WISTERIA DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-609-6789
Practice Address - Fax:678-395-4901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty