=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639095474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLE GA PEDIATRIC THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2026
-----------------------------------------------------
Last Update Date | 06/25/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4968 OLD GORDON RD
-----------------------------------------------------
City | DRY BRANCH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31020-1510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-621-8763
-----------------------------------------------------
Fax | 678-302-7270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 102
-----------------------------------------------------
City | DRY BRANCH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31020-0102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LESLEY HODGIN
-----------------------------------------------------
Credential | CCC-SLP
-----------------------------------------------------
Telephone | 478-621-8763
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------