Basic Information
Provider Information | |||||||||
NPI: | 1447499132 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTH GEORGIA PEDIATRIC THERAPIES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1821 BATTLEFIELD PKWY | ||||||||
Address2: |   | ||||||||
City: | FORT OGLETHORPE | ||||||||
State: | GA | ||||||||
PostalCode: | 307424021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068617471 | ||||||||
FaxNumber: | 7068617472 | ||||||||
Practice Location | |||||||||
Address1: | 118 HERRON STREET | ||||||||
Address2: |   | ||||||||
City: | FORT OGLETHORPE | ||||||||
State: | GA | ||||||||
PostalCode: | 307423126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7068617471 | ||||||||
FaxNumber: | 7068617472 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/19/2009 | ||||||||
LastUpdateDate: | 06/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINNICK | ||||||||
AuthorizedOfficialFirstName: | SHARON | ||||||||
AuthorizedOfficialMiddleName: | E. | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4233135895 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT, DPT | ||||||||
NPICertificationDate: | 06/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 225100000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 342148 | 01 | GA | WELLCARE | OTHER |