Healthcare Provider Details

I. General information

NPI: 1760139562
Provider Name (Legal Business Name): DEEPER ROOTS SPEECH THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10510 COLONY GLEN DR
JOHNS CREEK GA
30022-5791
US

IV. Provider business mailing address

10510 COLONY GLEN DR
JOHNS CREEK GA
30022-5791
US

V. Phone/Fax

Practice location:
  • Phone: 601-654-4912
  • Fax: 470-260-3110
Mailing address:
  • Phone: 601-654-4912
  • 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: MEGAN RENEE KELLY
Title or Position: OWNER/SPEECH-LANGUAGE PATHOLOGIST
Credential: MS, CCC-SLP
Phone: 423-915-6573