MEDICARE: ALBEMARLE SPEECH & LANGUAGE CTR, 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	4702	NC
2	235Z00000X	Speech-Language Pathologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	018Y1	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1073641825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBEMARLE SPEECH & LANGUAGE CTR, LLC

Provider Business Mailing Address
First Line	:	309 SELDEN ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-4661
Country	:	US
Telephone Number	:	252-619-5299
Fax Number	:	252-207-0450

Provider Business Practice Location Address
First Line	:	309 SELDEN ST
Second Line	:
City	:	ELIZABETH CITY
State	:	NC
Zip	:	27909-4661
Country	:	US
Telephone Number	:	252-619-5299
Fax Number	:	252-207-0450

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MS. HILARY AYERS DIETRICH
Credential	:	M.S., ED., CCC-SLP
Telephone Number	:	252-619-5299

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/09/2013

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