Provider Demographics
NPI:1619286374
Name:ELEMENTS OF SPEECH, SPEECH-LANGUAGE THERAPY, PLLC
Entity Type:Organization
Organization Name:ELEMENTS OF SPEECH, SPEECH-LANGUAGE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC/SLP
Authorized Official - Phone:919-359-2037
Mailing Address - Street 1:600 DEEP FOREST LN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-6270
Mailing Address - Country:US
Mailing Address - Phone:919-359-2037
Mailing Address - Fax:919-359-2038
Practice Address - Street 1:600 DEEP FOREST LN
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27527-6270
Practice Address - Country:US
Practice Address - Phone:919-359-2037
Practice Address - Fax:919-359-2038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200392Medicaid