Basic Information
| Provider Information | |||||||||
| NPI: | 1134538606 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABILITY PEDIATRIC THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2741 QUILLIANS DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305062885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708911362 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2741 QUILLIANS DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305062885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708911362 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2014 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | CORLEY | ||||||||
| AuthorizedOfficialFirstName: | LEIGH | ||||||||
| AuthorizedOfficialMiddleName: | MARSHALL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPY | ||||||||
| AuthorizedOfficialTelephone: | 7708911362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | P | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05935 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000812149E | 05 | GA | MEDICAID |