Provider Demographics
NPI:1316372659
Name:MOTOR MOUTH THERAPY, LLC
Entity Type:Organization
Organization Name:MOTOR MOUTH THERAPY, LLC
Other - Org Name:MOTOR MOUTH THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS-CCC-SLP
Authorized Official - Phone:678-820-9606
Mailing Address - Street 1:4530 NELSON BROGDON BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-5407
Mailing Address - Country:US
Mailing Address - Phone:678-820-9606
Mailing Address - Fax:844-820-9616
Practice Address - Street 1:4530 NELSON BROGDON BLVD STE C
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5407
Practice Address - Country:US
Practice Address - Phone:678-820-9606
Practice Address - Fax:844-820-9616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X, 235Z00000X
GA006456235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134692AMedicaid
GA198576913DMedicaid