Provider Demographics
NPI:1700490265
Name:CITRINE THERAPY SOURCE
Entity Type:Organization
Organization Name:CITRINE THERAPY SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAQUANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:678-640-5396
Mailing Address - Street 1:5678 GREENSAGE DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-8739
Mailing Address - Country:US
Mailing Address - Phone:678-640-5396
Mailing Address - Fax:
Practice Address - Street 1:5678 GREENSAGE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-8739
Practice Address - Country:US
Practice Address - Phone:678-640-5396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty