Organization
BLACK'S PEDIATRIC THERAPY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TINA BLACK (OWNER)
(770) 378-5986
Entity
Organization
Contact information
Practice address
4502 SUMMER GATE CT., GAINESVILLE, GA 30506
(770) 378-5986
Mailing address
4502 SUMMER GATE CT., GAINESVILLE, GA 30506
(770) 378-5986
Taxonomy
Speciality
Code
Description
License number
State
225XP0200X
Pediatric Occupational Therapist
Primary
003199
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10038361
AMERIGROUP- TINA
GA
01
—
10047944
AMERIGROUP-BETH CHAMBERS
GA
01
—
307327
TINA- WELLCARE
GA
Enumeration date
05/30/2007
Last updated
08/22/2020
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