Healthcare Provider Details

I. General information

NPI: 1639301567
Provider Name (Legal Business Name): ASPIRE PEDIATRIC THERAPY OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5745 OLD WINDER HWY SUITE C
BRASELTON GA
30517-1636
US

IV. Provider business mailing address

5745 OLD WINDER HWY SUITE C
BRASELTON GA
30517-1636
US

V. Phone/Fax

Practice location:
  • Phone: 770-965-1861
  • Fax: 770-965-1863
Mailing address:
  • Phone: 770-965-1861
  • Fax: 770-965-1863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT004005
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARGARET T VAN BUREN
Title or Position: EXECUTIVE DIRECTOR
Credential: OTR/L, ATP, SIPT
Phone: 770-965-1861