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General NPI Number Information
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NPI Number | 1861374381
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Entity Type | Organization
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Legal Business Name | GLOW FORWARD THERAPY, LLC
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Dates
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Enumeration Date | 07/24/2025
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Last Update Date | 07/24/2025
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Provider Practice Location Address
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Address Line | 1994 TOWNSHIP DR
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City | WINDER
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State | GA
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Zip | 30680-5633
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Country | US
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Telephone | 252-258-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 1994 TOWNSHIP DR
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City | WINDER
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State | GA
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Zip | 30680-5633
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Country | US
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Telephone | 252-258-6200
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Fax |
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Authorized Official
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Title or Position | MS, CCC-SLP
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Name | TRACI REID LEAK
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Credential |
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Telephone | 252-258-6200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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