=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255580239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUILDING BLOCKS PEDIATRICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2008
-----------------------------------------------------
Last Update Date | 09/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 JOHNSON FERRY PL I-20
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30068-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-643-0136
-----------------------------------------------------
Fax | 404-551-3891
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2840 PEACHTREE RD NW SUITE 411
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30305-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-643-0136
-----------------------------------------------------
Fax | 404-551-3891
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST/MEMBER
-----------------------------------------------------
Name | ERIN NOLAN ROSENKRANZ
-----------------------------------------------------
Credential | MS, OTR/L
-----------------------------------------------------
Telephone | 404-643-0136
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------