Healthcare Provider Details

I. General information

NPI: 1154408607
Provider Name (Legal Business Name): SALLY RAY MILLER PIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 CROWN POINT EXECUTIVE DR SUITE E
CHARLOTTE NC
28227-6725
US

IV. Provider business mailing address

2301 CROWN POINT EXECUTIVE DR SUITE E
CHARLOTTE NC
28227-6725
US

V. Phone/Fax

Practice location:
  • Phone: 704-708-8314
  • Fax: 704-708-8315
Mailing address:
  • Phone: 704-708-8314
  • Fax: 704-708-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number4234
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2583
License Number StateNC

VIII. Authorized Official

Name: MS. SALLY RAY PIDGE
Title or Position: OWNER THERAPIST
Credential: MED CCC-SLP
Phone: 704-708-8314