Healthcare Provider Details

I. General information

NPI: 1639095474
Provider Name (Legal Business Name): MIDDLE GA PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4968 OLD GORDON RD
DRY BRANCH GA
31020-1510
US

IV. Provider business mailing address

PO BOX 102
DRY BRANCH GA
31020-0102
US

V. Phone/Fax

Practice location:
  • Phone: 478-621-8763
  • Fax: 678-302-7270
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LESLEY HODGIN
Title or Position: OWNER
Credential: CCC-SLP
Phone: 478-621-8763