Provider Demographics
NPI:1467695734
Name:SPEECH ASSESSMENT CENTER, INC.
Entity Type:Organization
Organization Name:SPEECH ASSESSMENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-438-7168
Mailing Address - Street 1:210 MCINTOSH PLACE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7384
Mailing Address - Country:US
Mailing Address - Phone:678-438-7168
Mailing Address - Fax:707-377-8097
Practice Address - Street 1:175 BRADFORD SQ STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1967
Practice Address - Country:US
Practice Address - Phone:678-438-7168
Practice Address - Fax:470-377-8097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003209834DMedicaid