MEDICARE: SOUTHERN PEDIATRIC SPEECH THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053818351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN PEDIATRIC SPEECH THERAPY LLC

Provider Business Mailing Address
First Line	:	108 WALNUT ST
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-8535
Country	:	US
Telephone Number	:	912-658-6433
Fax Number	:

Provider Business Practice Location Address
First Line	:	108 WALNUT ST
Second Line	:
City	:	BLOOMINGDALE
State	:	GA
Zip	:	31302-8535
Country	:	US
Telephone Number	:	912-658-6433
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HOLLY HALES
Credential	:	SLP
Telephone Number	:	912-658-6433

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	06/16/2018

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