Healthcare Provider Details

I. General information

NPI: 1730619263
Provider Name (Legal Business Name): SOVEREIGN THERAPY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 08/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3867 HOLCOMB BRIDGE RD STE 400
PEACHTREE CORNERS GA
30092-2232
US

IV. Provider business mailing address

925 PEACHTREE ST NE STE B-509
ATLANTA GA
30309-3918
US

V. Phone/Fax

Practice location:
  • Phone: 678-421-4351
  • Fax:
Mailing address:
  • Phone: 678-421-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP006498
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. APRIL A MCRAE
Title or Position: SPEECH LANGUAGE PATHOLOGIST/CEO
Credential: SLP.D.,CCC-SLP
Phone: 678-421-4351