Provider Demographics
NPI:1922693613
Name:PEDIATRIC SALT CLINIC, LLC
Entity Type:Organization
Organization Name:PEDIATRIC SALT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:478-697-0459
Mailing Address - Street 1:915 BOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-2829
Mailing Address - Country:US
Mailing Address - Phone:478-697-0459
Mailing Address - Fax:
Practice Address - Street 1:915 BOXWOOD DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-2829
Practice Address - Country:US
Practice Address - Phone:478-697-0459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty