Healthcare Provider Details

I. General information

NPI: 1710392055
Provider Name (Legal Business Name): THERAPYLAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 SHILOH RD SUITE 100
ALPHARETTA GA
30005-8405
US

IV. Provider business mailing address

6505 SHILOH RD SUITE 100
ALPHARETTA GA
30005-8405
US

V. Phone/Fax

Practice location:
  • Phone: 678-648-7644
  • Fax: 678-648-7479
Mailing address:
  • Phone: 678-648-7644
  • Fax: 678-648-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1062816
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: THANE BROOKS
Title or Position: PRESIDENT
Credential:
Phone: 678-648-7644