Provider Demographics
NPI:1508400763
Name:RECESS PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:RECESS PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:931-241-1159
Mailing Address - Street 1:5908 COBBLESTONE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2654
Mailing Address - Country:US
Mailing Address - Phone:931-241-1159
Mailing Address - Fax:
Practice Address - Street 1:5908 COBBLESTONE CREEK CIR
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2654
Practice Address - Country:US
Practice Address - Phone:931-241-1159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty