Healthcare Provider Details

I. General information

NPI: 1376395632
Provider Name (Legal Business Name): SPECTRUM SUCCESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 WESTBROOK RD UNIT E
SUWANEE GA
30024-4987
US

IV. Provider business mailing address

3940 ESTATES PATH
CUMMING GA
30040-1030
US

V. Phone/Fax

Practice location:
  • Phone: 770-790-7413
  • Fax:
Mailing address:
  • Phone: 201-496-0525
  • 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: YAJURVANTHY CHEVALA
Title or Position: ORGANIZER
Credential:
Phone: 770-790-7413