1912429010 NPI number — SOUTHERN SPEECH PATHOLOGY SERVICES, LLC

Table of content: (NPI 1912429010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912429010 NPI number — SOUTHERN SPEECH PATHOLOGY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN SPEECH PATHOLOGY SERVICES, 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:
HOLLY MCDONALD HOWARD
Provider Other Organization Name Type Code:
3
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:
1912429010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2035 REBIE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUDLEY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31022-2411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-595-0317
Provider Business Mailing Address Fax Number:
--

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2035 REBIE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUDLEY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31022-2411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-595-0317
Provider Business Practice Location Address Fax Number:
--
Provider Enumeration Date:
07/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HOWARD
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
MCDONALD
Authorized Official Title or Position:
SOLE PROPRIETER
Authorized Official Telephone Number:
478-595-0317

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP005385 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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