Provider Demographics
NPI:1093839482
Name:THE SPEECH GARDEN, LLC
Entity Type:Organization
Organization Name:THE SPEECH GARDEN, LLC
Other - Org Name:THE SPEECH GARDEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:704-609-8255
Mailing Address - Street 1:2017 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5313
Mailing Address - Country:US
Mailing Address - Phone:704-609-8255
Mailing Address - Fax:704-371-7385
Practice Address - Street 1:2017 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5313
Practice Address - Country:US
Practice Address - Phone:704-609-8255
Practice Address - Fax:704-371-7385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-04-01
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
NC7211329Medicaid