MEDICARE: PROGRESS VILLAGE PEDIATRIC THERAPY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	001419	GA

General Provider Information

NPI Number	:	1144593047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROGRESS VILLAGE PEDIATRIC THERAPY SERVICES

Provider Business Mailing Address
First Line	:	2949 STONECREST PT
Second Line	:
City	:	CONYERS
State	:	GA
Zip	:	30094-4955
Country	:	US
Telephone Number	:	404-932-3440
Fax Number	:	770-483-3955

Provider Business Practice Location Address
First Line	:	2385 LAWRENCEVILLE HWY STE A
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-3168
Country	:	US
Telephone Number	:	404-289-4270
Fax Number	:	404-289-4428

Authorized Official
Title or Position	:	OWNER
Name	:	DIONNE BRUNSON
Credential	:	OTR/L
Telephone Number	:	404-932-3440

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	11/29/2024

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