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General NPI Number Information
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NPI Number | 1144593047
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Entity Type | Organization
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Legal Business Name | PROGRESS VILLAGE PEDIATRIC THERAPY SERVICES
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Dates
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Enumeration Date | 02/23/2012
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Last Update Date | 11/29/2024
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Provider Practice Location Address
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Address Line | 2385 LAWRENCEVILLE HWY STE A
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City | DECATUR
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State | GA
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Zip | 30033-3168
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Country | US
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Telephone | 404-289-4270
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Fax | 404-289-4428
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Provider Business Mailing Address
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Address Line | 2949 STONECREST PT
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City | CONYERS
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State | GA
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Zip | 30094-4955
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Country | US
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Telephone | 404-932-3440
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Fax | 770-483-3955
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Authorized Official
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Title or Position | OWNER
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Name | DIONNE BRUNSON
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Credential | OTR/L
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Telephone | 404-932-3440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 001419
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License Number State | GA
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