MEDICARE: THE SPEECH LILY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1073297826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SPEECH LILY LLC

Provider Business Mailing Address
First Line	:	1136 PONCE DE LEON AVE NE APT 4
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-4575
Country	:	US
Telephone Number	:	404-624-6492
Fax Number	:	404-806-4377

Provider Business Practice Location Address
First Line	:	1136 PONCE DE LEON AVE NE APT 4
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30306-4575
Country	:	US
Telephone Number	:	404-624-6492
Fax Number	:	404-806-4377

Authorized Official
Title or Position	:	SLP
Name	:	LILY BURNHAM
Credential	:
Telephone Number	:	404-624-6492

Provider Enumeration Date	:	06/12/2023
Last Update Date	:	09/05/2023

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Directions to “THE SPEECH LILY LLC ” Practice Location

Language	Start Address	Practice Location

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