Healthcare Provider Details

I. General information

NPI: 1720821416
Provider Name (Legal Business Name): AMARA PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4863 N HENRY BLVD
STOCKBRIDGE GA
30281-3521
US

IV. Provider business mailing address

337 MADISON AVENUE
STOCKBRIDGE GA
30228-5910
US

V. Phone/Fax

Practice location:
  • Phone: 719-505-4816
  • Fax:
Mailing address:
  • Phone: 719-505-4816
  • Fax:

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
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. RONTE JOHNSON
Title or Position: CEO/OWNER
Credential: BCBA
Phone: 719-505-4816