Provider Demographics
NPI:1770715724
Name:PEACHTREE CITY SPEECH AND LANGUAGE
Entity type:Organization
Organization Name:PEACHTREE CITY SPEECH AND LANGUAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MED-CCC/SLP
Authorized Official - Phone:7703-631-9299
Mailing Address - Street 1:277 HIGHWAY 74 N
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1569
Mailing Address - Country:US
Mailing Address - Phone:770-363-1929
Mailing Address - Fax:678-364-0858
Practice Address - Street 1:277 HIGHWAY 74 N
Practice Address - Street 2:SUITE 203
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1569
Practice Address - Country:US
Practice Address - Phone:770-363-1929
Practice Address - Fax:678-364-0858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA891207907AMedicaid