Healthcare Provider Details

I. General information

NPI: 1003469420
Provider Name (Legal Business Name): BY YOUR SIDE GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 BUSINESS PARK DR STE B
NORCROSS GA
30071-1428
US

IV. Provider business mailing address

3070 BUSINESS PARK DR STE B
NORCROSS GA
30071-1428
US

V. Phone/Fax

Practice location:
  • Phone: 770-884-1050
  • Fax: 770-884-1051
Mailing address:
  • Phone: 770-884-1050
  • Fax: 770-884-1051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW SULLIVAN
Title or Position: CFO
Credential:
Phone: 770-884-1050