Provider Demographics
NPI:1477964013
Name:PT FOUR KIDS LLC
Entity Type:Organization
Organization Name:PT FOUR KIDS LLC
Other - Org Name:PT4KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:MAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:404-509-9761
Mailing Address - Street 1:4458 WINDSOR OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2320
Mailing Address - Country:US
Mailing Address - Phone:404-509-9761
Mailing Address - Fax:678-981-6336
Practice Address - Street 1:4458 WINDSOR OAKS CIR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-2320
Practice Address - Country:US
Practice Address - Phone:404-509-9761
Practice Address - Fax:678-981-6336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002955252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000769315IMedicaid