=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689850398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPEECH AND LANGUAGE ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2008
-----------------------------------------------------
Last Update Date | 07/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 TAMIE CT
-----------------------------------------------------
City | KATHLEEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31047-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-397-7886
-----------------------------------------------------
Fax | 478-218-2715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105 TAMIE CT
-----------------------------------------------------
City | KATHLEEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31047-2222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-397-7886
-----------------------------------------------------
Fax | 478-218-2715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. SUSAN CARREKER DAUGHTRY
-----------------------------------------------------
Credential | MCD,CCC-SLP
-----------------------------------------------------
Telephone | 478-397-7886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | SLP001471
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------