Provider Demographics
NPI:1134385560
Name:GROW WITH ME PEDIATRIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:GROW WITH ME PEDIATRIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:HIDALGO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-463-6621
Mailing Address - Street 1:945 UMLAND RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-5446
Mailing Address - Country:US
Mailing Address - Phone:678-463-6621
Mailing Address - Fax:
Practice Address - Street 1:310 PAPER TRAIL WAY
Practice Address - Street 2:SUITE 302
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-5203
Practice Address - Country:US
Practice Address - Phone:770-345-2804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007123261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000937087BMedicaid