{
"Npi": {
"NPI": "1053839456",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "ROGERS BRIDGE PEDIATRIC THERAPY, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2845 SUMMERCREST LN",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DULUTH",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "30096-2776",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "478-454-8889",
"MailingAddressFaxNumber": "678-280-6766",
"FirstLinePracticeLocationAddress": "2845 SUMMERCREST LN",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DULUTH",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "30096",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "478-454-8889",
"PracticeLocationAddressFaxNumber": "678-280-6766",
"EnumerationDate": "09/06/2017",
"LastUpdateDate": "07/21/2022",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "WILLIS",
"AuthorizedOfficialFirstName": "JESSIE",
"AuthorizedOfficialMiddleName": "NELSON",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "CCC-SLP",
"AuthorizedOfficialTelephoneNumber": "478-454-8889",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QH0700X",
"TaxonomyName": "Hearing and Speech Clinic/Center",
"LicenseNumber": "SLP007707",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}