Provider Demographics
NPI:1881825057
Name:ACTIVEKIDZ & ADULT THERAPY SERVICES
Entity Type:Organization
Organization Name:ACTIVEKIDZ & ADULT THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:770-207-6390
Mailing Address - Street 1:1045 OLD MILL TRCE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30656-4379
Mailing Address - Country:US
Mailing Address - Phone:770-207-6390
Mailing Address - Fax:678-374-4855
Practice Address - Street 1:1949 HIGHWAY 81
Practice Address - Street 2:SUITE 100
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4537
Practice Address - Country:US
Practice Address - Phone:770-207-6390
Practice Address - Fax:678-374-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-05
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5588225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000875102BMedicaid