Healthcare Provider Details

I. General information

NPI: 1932359130
Provider Name (Legal Business Name): INTERACTIV CHILDREN'S THERAPY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2008
Last Update Date: 09/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2959 SHARPSBURG MCCULLUM RD BUILDING C, SUITE C
NEWNAN GA
30265-2297
US

IV. Provider business mailing address

2959 SHARPSBURG MCCULLUM RD BUILDING C, SUITE C
NEWNAN GA
30265-2297
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-0250
  • Fax: 770-683-4250
Mailing address:
  • Phone: 770-683-0250
  • Fax: 770-683-4250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: GREGG P MULVANY
Title or Position: GENERAL MANAGER / OWNER
Credential:
Phone: 770-683-0250