Provider Demographics
NPI:1700983772
Name:KIDS CREEK THERAPY
Entity Type:Organization
Organization Name:KIDS CREEK THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MYRLAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DARIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-888-5221
Mailing Address - Street 1:4055 JOHNS CREEK PKWY STE A
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1299
Mailing Address - Country:US
Mailing Address - Phone:770-888-5221
Mailing Address - Fax:678-680-5929
Practice Address - Street 1:4055 JOHNS CREEK PKWY STE A
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1299
Practice Address - Country:US
Practice Address - Phone:770-888-5221
Practice Address - Fax:678-680-5929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X, 106S00000X, 261QM1300X
GAPT008420225100000X
GAPT008827225100000X
GAOT003747225X00000X
GAOT001067225X00000X
GAOT003625225X00000X
GAOT001466225X00000X
GASLP004267235Z00000X
GASLP005105235Z00000X
GASLP005895235Z00000X
GASLP004972235Z00000X
GASLP006187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID #