Healthcare Provider Details

I. General information

NPI: 1669869863
Provider Name (Legal Business Name): SUNRISE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 TALMADGE LANE
CANTON GA
30115
US

IV. Provider business mailing address

604 TALMADGE LANE
CANTON GA
30115
US

V. Phone/Fax

Practice location:
  • Phone: 770-289-7113
  • Fax:
Mailing address:
  • Phone: 770-289-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC008069
License Number StateGA

VIII. Authorized Official

Name: MS. ALLISON R CORDTS
Title or Position: MENTAL HEALTH THERAPIST
Credential: LPC
Phone: 770-289-7113