1558622720 NPI number — ATLANTA WEST SPEECH-LANGUAGE PATHOLOGY AND ASSOCIATES, LLC

Table of content: (NPI 1558622720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558622720 NPI number — ATLANTA WEST SPEECH-LANGUAGE PATHOLOGY AND ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTA WEST SPEECH-LANGUAGE PATHOLOGY AND ASSOCIATES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
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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:
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NPI Number Information

NPI Number:
1558622720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1950
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUGLASVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30133-1950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-901-7788
Provider Business Mailing Address Fax Number:
866-400-4772

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6732 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-1760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-901-7788
Provider Business Practice Location Address Fax Number:
866-400-4772
Provider Enumeration Date:
06/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WHITE
Authorized Official First Name:
D'JARIS
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
SPEECH-LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
678-901-7788

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP005812 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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