=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851079628
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY JOSEPHINE OGLESBY M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2023
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2323 CUMBERLAND PKWY SE STE 104
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-4523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-927-7424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 FOOTHILLS PKWY NE
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-3825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-988-1120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP012138
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------