Provider Demographics
NPI:1083727325
Name:SPEECH PATHOLOGY ASSOCIATES OF SOUTH EAST GEORGIA, PC
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY ASSOCIATES OF SOUTH EAST GEORGIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:S
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:912-449-9923
Mailing Address - Street 1:4493 ARCH TRL
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-4210
Mailing Address - Country:US
Mailing Address - Phone:912-807-8255
Mailing Address - Fax:912-807-8255
Practice Address - Street 1:2976 US HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:BLACKSHEAR
Practice Address - State:GA
Practice Address - Zip Code:31516-4601
Practice Address - Country:US
Practice Address - Phone:912-807-8255
Practice Address - Fax:912-807-8256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003867235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000731464CMedicaid