Provider Demographics
NPI:1043580715
Name:123GROW
Entity Type:Organization
Organization Name:123GROW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC/SLP
Authorized Official - Phone:304-412-4246
Mailing Address - Street 1:624 SOUTH TER
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-1511
Mailing Address - Country:US
Mailing Address - Phone:304-412-4246
Mailing Address - Fax:
Practice Address - Street 1:624 SOUTH TER
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-1511
Practice Address - Country:US
Practice Address - Phone:304-412-4246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0802235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty