Healthcare Provider Details

I. General information

NPI: 1083727325
Provider Name (Legal Business Name): SPEECH PATHOLOGY ASSOCIATES OF SOUTH EAST GEORGIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2976 US HIGHWAY 84
BLACKSHEAR GA
31516-4601
US

IV. Provider business mailing address

4493 ARCH TRL
BLACKSHEAR GA
31516-4210
US

V. Phone/Fax

Practice location:
  • Phone: 912-807-8255
  • Fax: 912-807-8256
Mailing address:
  • Phone: 912-807-8255
  • Fax: 912-807-8255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP003867
License Number StateGA

VIII. Authorized Official

Name: SHANNON S BENNETT
Title or Position: OWNER
Credential: CCC-SLP
Phone: 912-449-9923