MEDICARE: PEACH SPEECH SERVICES, 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	005420	GA

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

General Provider Information

NPI Number	:	1194070599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACH SPEECH SERVICES, LLC

Provider Business Mailing Address
First Line	:	5190 ISLAND DR
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-4248
Country	:	US
Telephone Number	:	404-643-6098
Fax Number	:	877-245-3717

Provider Business Practice Location Address
First Line	:	5190 ISLAND DR
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30087-4248
Country	:	US
Telephone Number	:	404-643-6098
Fax Number	:	877-245-3717

Authorized Official
Title or Position	:	OWNER
Name	:	MYRIAM KATRINA ROBINSON
Credential	:	M.ED., CCC-SLP
Telephone Number	:	404-643-6098

Provider Enumeration Date	:	07/23/2012
Last Update Date	:	07/23/2012

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Directions to “PEACH SPEECH SERVICES, LLC ” Practice Location

Language	Start Address	Practice Location

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