Healthcare Provider Details

I. General information

NPI: 1336766831
Provider Name (Legal Business Name): I HEART THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 GILLSVILLE HWY
GAINESVILLE GA
30507-7940
US

IV. Provider business mailing address

2611 GILLSVILLE HWY
GAINESVILLE GA
30507-7940
US

V. Phone/Fax

Practice location:
  • Phone: 901-598-0190
  • Fax:
Mailing address:
  • Phone: 901-598-0190
  • 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 Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: DOMINIC HOLT
Title or Position: BEHAVIOR ANALYST
Credential: M.S.
Phone: 901-598-0190