Healthcare Provider Details

I. General information

NPI: 1194360768
Provider Name (Legal Business Name): ADVANT THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4827 OLD NATIONAL HWY PMB 1619
COLLEGE PARK GA
30337
US

IV. Provider business mailing address

4827 OLD NATIONAL HWY PMB 1619
COLLEGE PARK GA
30337
US

V. Phone/Fax

Practice location:
  • Phone: 732-822-8487
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MARK SAX
Title or Position: OWNER
Credential:
Phone: 732-822-8487