Provider Demographics
NPI:1790832566
Name:THERAPEUTIC DYNAMICS
Entity Type:Organization
Organization Name:THERAPEUTIC DYNAMICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PRESTON
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:770-232-7100
Mailing Address - Street 1:2557 COLLINS PORT CV
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2787
Mailing Address - Country:US
Mailing Address - Phone:770-232-7100
Mailing Address - Fax:770-232-7198
Practice Address - Street 1:1810 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8180
Practice Address - Country:US
Practice Address - Phone:770-232-7100
Practice Address - Fax:770-232-7198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006667225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9406564OtherPHCS PIN
GA52068657-004OtherBCBSGA PPO PIN
GA5675691OtherFIRST HEALTH PIN
GA681643OtherACN PIN
GA7480721OtherAETNA PPO POS PIN
GA52068657-004OtherBCBSGA PPO PIN
GA681643OtherACN PIN
GA7480721OtherAETNA PPO POS PIN