Provider Demographics
NPI:1639354962
Name:SAMUEL B. ELLIOTT
Entity type:Organization
Organization Name:SAMUEL B. ELLIOTT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH/LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MED,CCC-SLP
Authorized Official - Phone:404-835-2781
Mailing Address - Street 1:434 MARIETTA ST NW
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30313-1737
Mailing Address - Country:US
Mailing Address - Phone:404-835-2781
Mailing Address - Fax:404-835-2781
Practice Address - Street 1:434 MARIETTA ST NW
Practice Address - Street 2:SUITE 104
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30313-1737
Practice Address - Country:US
Practice Address - Phone:404-835-2781
Practice Address - Fax:404-835-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-06
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001044252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
SLP001044OtherGA. LICENSE
GA000697111JMedicaid