Provider Demographics
NPI:1972932028
Name:COMMUNITY KIDS PEDIATRIC THERAPY SERVICES
Entity type:Organization
Organization Name:COMMUNITY KIDS PEDIATRIC THERAPY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:LARAYNE
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:770-502-0303
Mailing Address - Street 1:90 GLENDA TRCE STE F
Mailing Address - Street 2:#414
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3868
Mailing Address - Country:US
Mailing Address - Phone:770-502-0303
Mailing Address - Fax:
Practice Address - Street 1:3229 HIGHWAY 34 E STE 103
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2196
Practice Address - Country:US
Practice Address - Phone:770-502-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006883235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty