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General NPI Number Information
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NPI Number | 1245796424
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Entity Type | Organization
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Legal Business Name | BSTSA INC DBA SPECTRUM THERAPY CENTER
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Dates
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Enumeration Date | 02/13/2019
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Last Update Date | 07/22/2020
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Provider Practice Location Address
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Address Line | 2346 WISTERIA DR
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City | SNELLVILLE
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State | GA
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Zip | 30078
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Country | US
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Telephone | 770-609-6789
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Fax | 678-395-4901
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Provider Business Mailing Address
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Address Line | 1373 CHLOE DR
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-8383
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Country | US
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Telephone | 843-655-3731
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRADFORD LEE TUCKER
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Credential |
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Telephone | 770-609-6789
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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