Provider Demographics
NPI:1558477695
Name:DUCKTAILS PEDIATRIC THERAPY AND WELLNESS
Entity Type:Organization
Organization Name:DUCKTAILS PEDIATRIC THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-364-5262
Mailing Address - Street 1:103 MAPLE DRIVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907
Mailing Address - Country:US
Mailing Address - Phone:706-364-5262
Mailing Address - Fax:706-364-5263
Practice Address - Street 1:568 BLUE RIDGE DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3604
Practice Address - Country:US
Practice Address - Phone:706-364-5262
Practice Address - Fax:706-364-5263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003593225XP0200X
GAPT004118261QP2000X
GAPT008564261QP2000X
GAPT004423261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000717274CMedicaid
GA000767456CMedicaid