=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558622720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA WEST SPEECH-LANGUAGE PATHOLOGY AND ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2012
-----------------------------------------------------
Last Update Date | 06/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6732 SPRING ST
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-1760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-901-7788
-----------------------------------------------------
Fax | 866-400-4772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1950
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30133-1950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-901-7788
-----------------------------------------------------
Fax | 866-400-4772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | DR. D'JARIS RENEE WHITE
-----------------------------------------------------
Credential | PH.D,
-----------------------------------------------------
Telephone | 678-901-7788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP005812
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------