Provider Demographics
NPI:1225770258
Name:IMMACULATE THERAPY
Entity Type:Organization
Organization Name:IMMACULATE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:843-461-7050
Mailing Address - Street 1:1143 FAULKNER WAY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-8075
Mailing Address - Country:US
Mailing Address - Phone:843-461-7050
Mailing Address - Fax:
Practice Address - Street 1:1143 FAULKNER WAY
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-8075
Practice Address - Country:US
Practice Address - Phone:843-461-7050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty