Provider Demographics
NPI:1184018731
Name:SMALL STEPS PEDIATRIC SPEECH THERAPY,LLC
Entity Type:Organization
Organization Name:SMALL STEPS PEDIATRIC SPEECH THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:912-667-6468
Mailing Address - Street 1:6 GABLES DR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9693
Mailing Address - Country:US
Mailing Address - Phone:912-667-6468
Mailing Address - Fax:
Practice Address - Street 1:6 GABLES DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9693
Practice Address - Country:US
Practice Address - Phone:912-667-6468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-22
Last Update Date:2015-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008055252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134193AMedicaid