Healthcare Provider Details

I. General information

NPI: 1225402639
Provider Name (Legal Business Name): OPTIMA PHYSICAL THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 COMMERCE BOULEVARD
RIVERDALE GA
30296
US

IV. Provider business mailing address

808 COMMERCE BOULEVARD
RIVERDALE GA
30296
US

V. Phone/Fax

Practice location:
  • Phone: 404-599-6567
  • Fax:
Mailing address:
  • Phone: 404-599-6567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCSW004266
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberCSW004266
License Number StateGA

VIII. Authorized Official

Name: SADAQA WARD
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 678-613-0430