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General NPI Number Information
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NPI Number | 1386465045
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Entity Type | Organization
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Legal Business Name | SOUTHPORT SPEECH AND LANGUAGE, PLLC
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Dates
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Enumeration Date | 10/24/2024
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Last Update Date | 10/24/2024
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Provider Practice Location Address
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Address Line | 1746 E CORONADO AVE SE
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City | BOLIVIA
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State | NC
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Zip | 28422-0900
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Country | US
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Telephone | 336-404-4802
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Fax |
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Provider Business Mailing Address
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Address Line | 1746 E CORONADO AVE SE
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City | BOLIVIA
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State | NC
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Zip | 28422-0900
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Country | US
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Telephone | 336-404-4802
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LAURA ANN MCDANIEL O'CONNELL
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Credential | SLP
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Telephone | 336-404-4802
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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 |
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License Number State |
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