Provider Demographics
NPI:1225541600
Name:BROOKHAVEN SPEECH,LLC
Entity Type:Organization
Organization Name:BROOKHAVEN SPEECH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICHAN
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:904-540-6762
Mailing Address - Street 1:2870 PEACHTREE RD NW # 293
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2918
Mailing Address - Country:US
Mailing Address - Phone:904-540-6762
Mailing Address - Fax:
Practice Address - Street 1:77 E ANDREWS DR NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1370
Practice Address - Country:US
Practice Address - Phone:904-540-6762
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty