Healthcare Provider Details

I. General information

NPI: 1437553096
Provider Name (Legal Business Name): DREW KOLETSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2014
Last Update Date: 03/22/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 RACETRACK RD STE 102
MCDONOUGH GA
30252-1022
US

IV. Provider business mailing address

3450 ROXBORO RD NE APT 2401
ATLANTA GA
30326-1686
US

V. Phone/Fax

Practice location:
  • Phone: 678-691-2206
  • Fax:
Mailing address:
  • Phone: 561-901-8717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47760
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: