Provider Demographics
NPI:1265213359
Name:EXPRESSIVE PEDIATRIC THERAPY
Entity type:Organization
Organization Name:EXPRESSIVE PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ASIAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILBORN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:678-349-6151
Mailing Address - Street 1:1691 COBBLEFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7682
Mailing Address - Country:US
Mailing Address - Phone:678-349-6151
Mailing Address - Fax:
Practice Address - Street 1:1691 COBBLEFIELD CIR
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7682
Practice Address - Country:US
Practice Address - Phone:678-349-6151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-13
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty