MEDICARE: KIDS CREEK THERAPY

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	PT008827	GA
2	225X00000X	Occupational Therapist	OT003747	GA
3	225X00000X	Occupational Therapist	OT001067	GA
4	225X00000X	Occupational Therapist	OT003625	GA
5	225X00000X	Occupational Therapist	OT001466	GA
6	103K00000X	Behavior Analyst
7	106E00000X	Assistant Behavior Analyst
8	106S00000X	Behavior Technician
9	225100000X	Physical Therapist	PT008420	GA
10	235Z00000X	Speech-Language Pathologist	SLP004267	GA
11	235Z00000X	Speech-Language Pathologist	SLP005105	GA
12	235Z00000X	Speech-Language Pathologist	SLP005895	GA
13	235Z00000X	Speech-Language Pathologist	SLP006187	GA
14	235Z00000X	Speech-Language Pathologist	SLP004972	GA
15	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1700983772
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS CREEK THERAPY

Provider Business Mailing Address
First Line	:	4055 JOHNS CREEK PKWY STE A
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-1299
Country	:	US
Telephone Number	:	770-888-5221
Fax Number	:	678-680-5929

Provider Business Practice Location Address
First Line	:	4055 JOHNS CREEK PKWY STE A
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-1299
Country	:	US
Telephone Number	:	770-888-5221
Fax Number	:	678-680-5929

Authorized Official
Title or Position	:	ADMIN DIRECTOR
Name	:	MYRLAINE DARIUS
Credential	:
Telephone Number	:	770-888-5221

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	10/02/2023

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Directions to “KIDS CREEK THERAPY ” Practice Location

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