MEDICARE: VICTORY SPEECH-LANGUAGE 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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1417482753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY SPEECH-LANGUAGE THERAPY, LLC

Provider Business Mailing Address
First Line	:	375 HIGHLAND AVE NE UNIT 914
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-1387
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 HIGHLAND AVE NE UNIT 914
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30312-1387
Country	:	US
Telephone Number	:	954-263-7191
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JODIE VICTOR
Credential	:	M.S., CCC-SLP
Telephone Number	:	954-263-7191

Provider Enumeration Date	:	04/24/2017
Last Update Date	:	04/24/2017

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Directions to “VICTORY SPEECH-LANGUAGE THERAPY, LLC ” Practice Location

Language	Start Address	Practice Location

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