Healthcare Provider Details

I. General information

NPI: 1124342019
Provider Name (Legal Business Name): PROFESSIONAL SPEECH & LANGUAGE THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2010
Last Update Date: 03/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 WALKER ST SW UNIT 5
ATLANTA GA
30313-1213
US

IV. Provider business mailing address

210 WALKER ST SW UNIT 5
ATLANTA GA
30313-1213
US

V. Phone/Fax

Practice location:
  • Phone: 678-608-9601
  • Fax: 404-748-4482
Mailing address:
  • Phone: 678-608-9601
  • Fax: 404-748-4482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS JAVONYA DONELL CLEMONS
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: M.S. CCC-SLP
Phone: 678-608-9601