Healthcare Provider Details

I. General information

NPI: 1477754067
Provider Name (Legal Business Name): BLACK'S PEDIATRIC THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 SUMMER GATE CT.
GAINESVILLE GA
30506
US

IV. Provider business mailing address

4502 SUMMER GATE CT.
GAINESVILLE GA
30506
US

V. Phone/Fax

Practice location:
  • Phone: 770-378-5986
  • Fax:
Mailing address:
  • Phone: 770-378-5986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number003199
License Number StateGA

VIII. Authorized Official

Name: TINA BLACK
Title or Position: OWNER
Credential:
Phone: 770-378-5986