MEDICARE: THRIVE PEDIATRIC THERAPY GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP005342	GA
2	235Z00000X	Speech-Language Pathologist	SLP004848	GA

General Provider Information

NPI Number	:	1285007625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THRIVE PEDIATRIC THERAPY GROUP

Provider Business Mailing Address
First Line	:	1596 CLEVELAND AVE
Second Line	:	UNIT 103
City	:	EAST POINT
State	:	GA
Zip	:	30344-3205
Country	:	US
Telephone Number	:	404-975-3080
Fax Number	:	888-886-0460

Provider Business Practice Location Address
First Line	:	1596 CLEVELAND AVE
Second Line	:	UNIT 103
City	:	EAST POINT
State	:	GA
Zip	:	30344-3205
Country	:	US
Telephone Number	:	404-975-3080
Fax Number	:	888-886-0460

Authorized Official
Title or Position	:	OWNER/SPEECH LANGUAGE PATHOLOGIST
Name	:	MRS. CHIQUITA SMITH
Credential	:	M.A. CCC-SLP
Telephone Number	:	404-867-1682

Provider Enumeration Date	:	11/06/2015
Last Update Date	:	11/06/2015

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