Provider Demographics
NPI:1316014616
Name:THOMPSON, BEVERLY B (SLP)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:B
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 WEYERHAEUSER RD
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:GA
Mailing Address - Zip Code:30436-2608
Mailing Address - Country:US
Mailing Address - Phone:912-526-6732
Mailing Address - Fax:
Practice Address - Street 1:1416 WEYERHAEUSER RD
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-2608
Practice Address - Country:US
Practice Address - Phone:912-526-6732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001980235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00658369BMedicaid
GA10049370OtherAMERIGROUP PROVIDER #
GA341006OtherWELLCARE PROVIDER #