Provider Demographics
NPI:1942435201
Name:BAUCH, ALYCIA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:
Last Name:BAUCH
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ALYCIA
Other - Middle Name:
Other - Last Name:BAUCH WHITNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:365 S INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3075
Mailing Address - Country:US
Mailing Address - Phone:706-624-3000
Mailing Address - Fax:706-624-3001
Practice Address - Street 1:365 S INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-3075
Practice Address - Country:US
Practice Address - Phone:706-624-3000
Practice Address - Fax:706-624-3001
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00403400235Z00000X
PASL007286235Z00000X
SC6092235Z00000X
GASLP008164235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1815Medicaid