Healthcare Provider Details

I. General information

NPI: 1073709002
Provider Name (Legal Business Name): MCKENNA FARMS THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3044 DUE WEST RD
DALLAS GA
30157-2125
US

IV. Provider business mailing address

3044 DUE WEST RD
DALLAS GA
30157-2125
US

V. Phone/Fax

Practice location:
  • Phone: 770-443-9672
  • Fax: 770-505-3595
Mailing address:
  • Phone: 770-443-9672
  • Fax: 770-505-3595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT004432
License Number StateGA

VIII. Authorized Official

Name: MRS. CHERYL ZIEGLER
Title or Position: BILLING ADMINISTRATOR
Credential:
Phone: 770-432-8996