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General NPI Number Information
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NPI Number | 1619309994
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Entity Type | Organization
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Legal Business Name | PRESTIGE LEARNING ACADEMY
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Dates
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Enumeration Date | 08/08/2013
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Last Update Date | 08/08/2013
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Provider Practice Location Address
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Address Line | 6920 BROAD ST
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-1604
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Country | US
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Telephone | 248-943-5234
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Fax |
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Provider Business Mailing Address
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Address Line | 6920 BROAD ST
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-1604
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Country | US
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Telephone | 248-943-5234
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Fax |
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MONNIQUE MILLINER
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Credential | ED SPECIALIST/MASTER
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Telephone | 248-943-5234
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 739025
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License Number State | GA
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