Provider Demographics
NPI:1366031908
Name:FUNCTIONAL THERAPIST LLC
Entity Type:Organization
Organization Name:FUNCTIONAL THERAPIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:678-684-8245
Mailing Address - Street 1:80 LEGION DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2692
Mailing Address - Country:US
Mailing Address - Phone:678-684-8244
Mailing Address - Fax:
Practice Address - Street 1:80 LEGION DR
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-2692
Practice Address - Country:US
Practice Address - Phone:678-684-8244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-17
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty