Healthcare Provider Details

I. General information

NPI: 1215636295
Provider Name (Legal Business Name): PRACTICAL CHILD THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7033 GRAND HICKORY DR
BRASELTON GA
30517-6253
US

IV. Provider business mailing address

7033 GRAND HICKORY DR
BRASELTON GA
30517-6253
US

V. Phone/Fax

Practice location:
  • Phone: 678-951-4122
  • Fax:
Mailing address:
  • Phone: 678-951-4122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL RAYMOND SEMONSKY
Title or Position: PARTNER
Credential:
Phone: 678-951-4122