Provider Demographics
NPI:1053818351
Name:SOUTHERN PEDIATRIC SPEECH THERAPY LLC
Entity Type:Organization
Organization Name:SOUTHERN PEDIATRIC SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALES
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:912-658-6433
Mailing Address - Street 1:108 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:GA
Mailing Address - Zip Code:31302-8535
Mailing Address - Country:US
Mailing Address - Phone:912-658-6433
Mailing Address - Fax:
Practice Address - Street 1:108 WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:GA
Practice Address - Zip Code:31302-8535
Practice Address - Country:US
Practice Address - Phone:912-658-6433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003195129AMedicaid