Provider Demographics
NPI:1821464124
Name:VAN VARICK PEDIATRIC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:VAN VARICK PEDIATRIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SAINT JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:561-707-5209
Mailing Address - Street 1:1000 HOLCOMB WOODS PKWY
Mailing Address - Street 2:SUITE 422
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 HOLCOMB WOODS PKWY
Practice Address - Street 2:SUITE 422
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2575
Practice Address - Country:US
Practice Address - Phone:770-641-8070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012056225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty