Provider Demographics
NPI:1073032884
Name:INDIVIDUAL EXPRESSIONS THERAPY, LLC
Entity Type:Organization
Organization Name:INDIVIDUAL EXPRESSIONS THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NILKA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:770-731-8772
Mailing Address - Street 1:7421 DOUGLAS BLVD STE N446
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1564
Mailing Address - Country:US
Mailing Address - Phone:770-731-8772
Mailing Address - Fax:470-300-0042
Practice Address - Street 1:7421 DOUGLAS BLVD STE N446
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1564
Practice Address - Country:US
Practice Address - Phone:770-731-8772
Practice Address - Fax:470-300-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003147217DMedicaid