Provider Demographics
NPI:1477754067
Name:BLACK'S PEDIATRIC THERAPY, INC.
Entity Type:Organization
Organization Name:BLACK'S PEDIATRIC THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-378-5986
Mailing Address - Street 1:4502 SUMMER GATE CT.
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506
Mailing Address - Country:US
Mailing Address - Phone:770-378-5986
Mailing Address - Fax:
Practice Address - Street 1:4502 SUMMER GATE CT.
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506
Practice Address - Country:US
Practice Address - Phone:770-378-5986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003199225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10038361OtherAMERIGROUP- TINA
GA307327OtherTINA- WELLCARE
GA10047944OtherAMERIGROUP-BETH CHAMBERS