Healthcare Provider Details

I. General information

NPI: 1740538701
Provider Name (Legal Business Name): THERAPY ON THE GO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2012
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 TRAVELERS REST RD
MONTEZUMA GA
31063-2032
US

IV. Provider business mailing address

405 TRAVELERS REST RD
MONTEZUMA GA
31063-2032
US

V. Phone/Fax

Practice location:
  • Phone: 478-244-0926
  • Fax: 478-472-1207
Mailing address:
  • Phone: 478-244-0926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateGA

VIII. Authorized Official

Name: DAWN JAMES
Title or Position: OWNER
Credential: LPC
Phone: 478-244-0926