Basic Information
| Provider Information | |||||||||
| NPI: | 1932359130 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERACTIV CHILDREN'S THERAPY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2959 SHARPSBURG MCCULLUM RD | ||||||||
| Address2: | BUILDING C, SUITE C | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302652297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706830250 | ||||||||
| FaxNumber: | 7706834250 | ||||||||
| Practice Location | |||||||||
| Address1: | 2959 SHARPSBURG MCCULLUM RD | ||||||||
| Address2: | BUILDING C, SUITE C | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302652297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706830250 | ||||||||
| FaxNumber: | 7706834250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2008 | ||||||||
| LastUpdateDate: | 09/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | MULVANY | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL MANAGER / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7706830250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.