MEDICARE: HOLLY HALES M.S., CCC-SLP

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	235Z00000X	Speech-Language Pathologist	1189302	GA

General Provider Information

NPI Number	:	1215368089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY HALES M.S., CCC-SLP

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2013
Last Update Date	:	12/04/2013

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Directions to “ HOLLY HALES M.S., CCC-SLP” Practice Location

Language	Start Address	Practice Location

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