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General NPI Number Information
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NPI Number | 1043580715
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Entity Type | Organization
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Legal Business Name | 123GROW
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Dates
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Enumeration Date | 01/11/2012
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 624 SOUTH TER
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City | HUNTINGTON
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State | WV
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Zip | 25705-1511
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Country | US
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Telephone | 304-412-4246
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Fax |
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Provider Business Mailing Address
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Address Line | 624 SOUTH TER
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City | HUNTINGTON
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State | WV
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Zip | 25705-1511
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Country | US
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Telephone | 304-412-4246
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Fax |
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Authorized Official
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Title or Position | SPEECH PATHOLOGIST
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Name | MS. SUSAN PAY
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Credential | MA, CCC/SLP
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Telephone | 304-412-4246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP-0802
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License Number State | WV
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