Provider Demographics
NPI:1073676623
Name:SPEECH PATHOLOGY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:N
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:601-833-8363
Mailing Address - Street 1:20 THE RAYS TRL SE
Mailing Address - Street 2:
Mailing Address - City:BOGUE CHITTO
Mailing Address - State:MS
Mailing Address - Zip Code:39629-8500
Mailing Address - Country:US
Mailing Address - Phone:601-833-8363
Mailing Address - Fax:601-833-0080
Practice Address - Street 1:20 THE RAYS TRL SE
Practice Address - Street 2:
Practice Address - City:BOGUE CHITTO
Practice Address - State:MS
Practice Address - Zip Code:39629-8500
Practice Address - Country:US
Practice Address - Phone:601-833-8363
Practice Address - Fax:601-833-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
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
MS09016222Medicaid