NPIMap

Organization Active NPI

Fundamental Therapy Services, LLC

  • Occupational Therapist
  • Clayton, GA
National Provider Identifier
1780110155
Registry record updated Oct 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Occupational TherapistTaxonomy code 225X00000X
Legal business name
FUNDAMENTAL THERAPY SERVICES, LLC
Practice address
165 Ridgecrest Cir
Clayton, GA 30525-4110
Phone
(678) 357-5849
NPI assigned
May 4, 2017
Last updated
Oct 30, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Jennifer Marie Deslich, MS, OTR/LNPI 1790107993
Title
Owner
Phone
(678) 357-5849

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Occupational TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225X00000X Primary

Addresses

Primary practice location

165 Ridgecrest Cir
Clayton, GA 30525-4110

Mailing address

4649 E Wolf Creek Rd
Tiger, GA 30576-2946
Phone (678) 357-5849

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20181011002104 GA Part B Supplier - Clinic/Group Practice 4789936113 Receives reassigned benefits from 4 practitioners
Practice locations: Clayton, GA

National Provider Directory

National Provider Directory

Locations

165 Ridgecrest Cir
Clayton, GA 30525
Phone (678) 357-5849

165 Ridgecrest Cir
Ste B
Clayton, GA 30525
Phone (678) 357-5849

Practitioners & affiliated clinicians

Practitioners 12

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1493856000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698624000000",
    "number": "1780110155",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4649 E WOLF CREEK RD",
            "city": "TIGER",
            "state": "GA",
            "postal_code": "305762946",
            "telephone_number": "678-357-5849"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "165 RIDGECREST CIR",
            "city": "CLAYTON",
            "state": "GA",
            "postal_code": "305254110",
            "telephone_number": "678-357-5849"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FUNDAMENTAL THERAPY SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-04",
        "last_updated": "2023-10-30",
        "certification_date": "2023-10-30",
        "status": "A",
        "authorized_official_last_name": "DESLICH",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "678-357-5849",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MS, OTR/L"
    },
    "taxonomies": [
        {
            "code": "225X00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Occupational Therapist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Clayton, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.