1760933287 NPI number — RECONNECT THERAPEUTIC ASSOCIATES LLC.

Table of content: (NPI 1760933287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760933287 NPI number — RECONNECT THERAPEUTIC ASSOCIATES LLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RECONNECT THERAPEUTIC ASSOCIATES LLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760933287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1264 CONCORD RD SE STE 106
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30080-5302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-424-8650
Provider Business Mailing Address Fax Number:
678-424-8653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1264 CONCORD RD SE
Provider Second Line Business Practice Location Address:
SE SUITE 106
Provider Business Practice Location Address City Name:
SMYRNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30080-5302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-424-8650
Provider Business Practice Location Address Fax Number:
678-424-8653
Provider Enumeration Date:
10/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
RICHARDSON
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
RONAY
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
678-424-8650

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LPC007466 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003153870A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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