=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841664372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTA SPEECH PATHOLOGY, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2015
-----------------------------------------------------
Last Update Date | 01/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 241 W WIEUCA RD NE STE. 120
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-3367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-258-2058
-----------------------------------------------------
Fax | 404-601-5442
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 241 W WIEUCA RD NE STE. 120
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-3367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax | 404-601-5442
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH-LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | JESSICA WILLIAMS
-----------------------------------------------------
Credential | M.ED, CCC-SLP
-----------------------------------------------------
Telephone | 470-258-2058
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP008175
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------