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General NPI Number Information
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NPI Number | 1962633131
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Entity Type | Organization
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Legal Business Name | ACTIVEKIDZ AND ADULT THERAPY SERVICES
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Dates
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Enumeration Date | 08/05/2009
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Last Update Date | 04/25/2024
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Provider Practice Location Address
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Address Line | 1071 THOMAS AVE
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City | WATKINSVILLE
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State | GA
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Zip | 30677-6073
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Country | US
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Telephone | 770-207-6390
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Fax | 678-374-4855
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Provider Business Mailing Address
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Address Line | 1431 CAPITAL AVE STE 123
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City | WATKINSVILLE
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State | GA
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Zip | 30677-1883
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Country | US
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Telephone | 706-338-8058
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Fax | 678-374-4855
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN COOK
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Credential | PT
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Telephone | 770-207-6390
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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 | 3287
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 5359
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5588
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License Number State | GA
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