Provider Demographics
NPI:1073884482
Name:AGAPE SPEECH THERAPY, LLC
Entity Type:Organization
Organization Name:AGAPE SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:770-776-6013
Mailing Address - Street 1:101 DEVANT ST
Mailing Address - Street 2:SUITE 703
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2710
Mailing Address - Country:US
Mailing Address - Phone:770-776-6013
Mailing Address - Fax:877-469-5558
Practice Address - Street 1:101 DEVANT ST
Practice Address - Street 2:SUITE 703
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2710
Practice Address - Country:US
Practice Address - Phone:770-776-6013
Practice Address - Fax:877-469-5558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-17
Last Update Date:2014-06-04
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
GA202G155590OtherMEDICARE
GA003125104BMedicaid
GA12362429OtherCAQH