Provider Demographics
NPI:1548219652
Name:PIDGE, SALLY RAY (SLP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:RAY
Last Name:PIDGE
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 1:10800 INDEPENDENCE POINTE PKWY
Mailing Address - Street 2:SUITE D
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-1753
Mailing Address - Country:US
Mailing Address - Phone:704-708-8314
Mailing Address - Fax:
Practice Address - Street 1:10800 INDEPENDENCE POINTE PKWY
Practice Address - Street 2:SUITE D
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1753
Practice Address - Country:US
Practice Address - Phone:704-708-8314
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC2583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411122Medicaid