=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588262257
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN SPEECH SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2020
-----------------------------------------------------
Last Update Date | 10/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 PLEASANT LN
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31533-8028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-590-2516
-----------------------------------------------------
Fax | 912-214-5206
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 PLEASANT LN
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31533-8028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-590-2516
-----------------------------------------------------
Fax | 912-214-5206
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | JODI M WILLIAMS
-----------------------------------------------------
Credential | CCC/SLP
-----------------------------------------------------
Telephone | 912-590-2516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------