Healthcare Provider Details

I. General information

NPI: 1982133237
Provider Name (Legal Business Name): KIDBRIDGE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2384 GARDEN HILLS LOOP
RICHMOND HILL GA
31324-6091
US

IV. Provider business mailing address

2384 GARDEN HILLS LOOP
RICHMOND HILL GA
31324-6091
US

V. Phone/Fax

Practice location:
  • Phone: 912-663-4118
  • Fax:
Mailing address:
  • Phone: 912-663-4118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT005053
License Number StateGA

VIII. Authorized Official

Name: CRYSTAL NICOLE REYNOLDS
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: MSOTR/L
Phone: 912-663-4118