MEDICARE: THE ATLANTA MEDICAL SPEECH PATHOLOGY GROUP

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	261QH0700X	Hearing and Speech Clinic/Center

General Provider Information

NPI Number	:	1265008106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE ATLANTA MEDICAL SPEECH PATHOLOGY GROUP

Provider Business Mailing Address
First Line	:	1568 SPRING HOLLOW WAY
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-1333
Country	:	US
Telephone Number	:	678-654-1869
Fax Number	:

Provider Business Practice Location Address
First Line	:	1568 SPRING HOLLOW WAY
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-1333
Country	:	US
Telephone Number	:	678-654-1869
Fax Number	:

Authorized Official
Title or Position	:	OWNER, SPEECH PATHOLOGIST
Name	:	JILLIAN PAIGE HICKS
Credential	:
Telephone Number	:	678-654-1869

Provider Enumeration Date	:	06/01/2021
Last Update Date	:	06/01/2021

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