Provider Demographics
NPI:1710346267
Name:PEDIATRIC THERAPIES OF SE GA, LLC
Entity Type:Organization
Organization Name:PEDIATRIC THERAPIES OF SE GA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-996-2069
Mailing Address - Street 1:5200 SAN JOSE BLVD
Mailing Address - Street 2:UNIT 7
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-1905
Mailing Address - Country:US
Mailing Address - Phone:912-996-2069
Mailing Address - Fax:912-265-0041
Practice Address - Street 1:1204 HOSPITALITY AVE
Practice Address - Street 2:SUITE E
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6810
Practice Address - Country:US
Practice Address - Phone:912-996-2069
Practice Address - Fax:912-265-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-12
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001375225XP0200X
GAOT005680225XP0200X
GAOT002198225XP0200X
GASLP001592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty