Healthcare Provider Details

I. General information

NPI: 1083143135
Provider Name (Legal Business Name): WIGGLE WORM THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9137 LOXFORD ST
LITHIA SPRINGS GA
30122-6414
US

IV. Provider business mailing address

9137 LOXFORD ST
LITHIA SPRINGS GA
30122-6414
US

V. Phone/Fax

Practice location:
  • Phone: 678-978-6614
  • Fax:
Mailing address:
  • Phone: 678-978-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TAKEISHA MANN
Title or Position: CEO
Credential:
Phone: 678-214-3666