=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639359169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH METRO THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2007
-----------------------------------------------------
Last Update Date | 01/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3097 DAWSON LN SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-5473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-793-5963
-----------------------------------------------------
Fax | 949-955-7203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3097 DAWSON LN SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-5473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-793-5963
-----------------------------------------------------
Fax | 949-955-7203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | BRIAN C RICHBERG
-----------------------------------------------------
Credential | SLP
-----------------------------------------------------
Telephone | 678-793-9563
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP005324
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------