Provider Demographics
NPI:1689755241
Name:CAPITOL CITY SPEECH THERAPY, LLC
Entity Type:Organization
Organization Name:CAPITOL CITY SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LORRINE
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:919-577-6807
Mailing Address - Street 1:141 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-1933
Mailing Address - Country:US
Mailing Address - Phone:919-577-6807
Mailing Address - Fax:919-577-6853
Practice Address - Street 1:141 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1933
Practice Address - Country:US
Practice Address - Phone:919-577-6807
Practice Address - Fax:919-577-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4178235Z00000X, 235Z00000X
251S00000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016U8OtherBC/BS GROUP NUMBER
NC7412076Medicaid
NCD3268OtherMEDCOST INDIVIDUAL NUMBER
NC7211674Medicaid
NCA9389OtherMEDCOST GROUP NUMBER
NC1359HOtherBC/BS INDIVIDUAL NUMBER
NC7211674Medicaid