1164135653 NPI number — MERRITT C LOGAN SPEECH LANGUAGE PATHOLOGY

Table of content: (NPI 1164135653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164135653 NPI number — MERRITT C LOGAN SPEECH LANGUAGE PATHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRITT C LOGAN SPEECH LANGUAGE PATHOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
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Provider Other Last Name:
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NPI Number Information

NPI Number:
1164135653
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 PENDLETON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31721-9220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2411 WESTGATE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31707-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-869-1328
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BRIMER
Authorized Official First Name:
SHELLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
706-206-4434

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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