1063097889 NPI number — PREFERRED PRACTICE SPEECH PATHOLOGY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063097889 NPI number — PREFERRED PRACTICE SPEECH PATHOLOGY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED PRACTICE SPEECH PATHOLOGY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063097889
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4783 CAMP HIGHLAND RD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30082-5017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-890-7720
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PREFERRED PRACTICE SPEECH PATHOLOGY, LLC
Provider Second Line Business Practice Location Address:
1700 NORTHSIDE DRIVE SUITE A7 PMB 801
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-890-7720
Provider Business Practice Location Address Fax Number:
404-645-7787
Provider Enumeration Date:
03/12/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MANUEL-MOTEN
Authorized Official First Name:
LORNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-890-7720

Provider Taxonomy Codes

  • Taxonomy code: 261QH0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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