=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952779043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC OCCUPATIONAL AND PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2015
-----------------------------------------------------
Last Update Date | 05/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5835 CAMPBELTON RD. STE. 304
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-7491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-458-6139
-----------------------------------------------------
Fax | 678-550-9066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5835 CAMPBELTON RD. STE. 304
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-7491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-458-6139
-----------------------------------------------------
Fax | 678-550-9066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. KEITORIA LACOUNT
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 404-458-6139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | OT004692
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------