Provider Demographics
NPI:1528549797
Name:EASON, KALEIGH MARIE (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KALEIGH
Middle Name:MARIE
Last Name:EASON
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S 2ND ST SE
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30147-1224
Mailing Address - Country:US
Mailing Address - Phone:706-767-9883
Mailing Address - Fax:706-767-9883
Practice Address - Street 1:304 TURNER MCCALL BLVD SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-5621
Practice Address - Country:US
Practice Address - Phone:706-509-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002795235Z00000X
GASLP010634235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP010634OtherGA LICENSE