Provider Demographics
NPI:1255834669
Name:SMART MOUTHS SPEECH THERAPY
Entity Type:Organization
Organization Name:SMART MOUTHS SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:ALBERTINE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:757-714-6224
Mailing Address - Street 1:242 GRANDIFLORA DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8012
Mailing Address - Country:US
Mailing Address - Phone:757-714-6224
Mailing Address - Fax:
Practice Address - Street 1:242 GRANDIFLORA DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8012
Practice Address - Country:US
Practice Address - Phone:757-714-6224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty