MEDICARE: ACTIVEKIDZ AND ADULT 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	225100000X	Physical Therapist	7510	GA
2	225X00000X	Occupational Therapist	4397	GA
3	225100000X	Physical Therapist	5588	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326120932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVEKIDZ AND ADULT THERAPY SERVICES

Provider Business Mailing Address
First Line	:	1431 CAPITAL AVE STE 123
Second Line	:
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-1883
Country	:	US
Telephone Number	:	770-207-6390
Fax Number	:	678-374-4855

Provider Business Practice Location Address
First Line	:	1045 OLD MILL TRCE
Second Line	:
City	:	MONROE
State	:	GA
Zip	:	30656-4379
Country	:	US
Telephone Number	:	770-207-6390
Fax Number	:	678-374-4855

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN COOK
Credential	:	PT
Telephone Number	:	770-207-6390

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	04/25/2024

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Directions to “ACTIVEKIDZ AND ADULT THERAPY SERVICES ” Practice Location

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