Organization
SOUTHERN PEDIATRIC SPEECH THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HOLLY HALES SLP (OWNER)
(912) 658-6433
Entity
Organization
Contact information
Practice address
108 WALNUT ST, BLOOMINGDALE, GA 31302-8535
(912) 658-6433
Mailing address
108 WALNUT ST, BLOOMINGDALE, GA 31302-8535
(912) 658-6433
Taxonomy
Speciality
Code
Description
License number
State
252Y00000X
Early Intervention Provider Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003195129A
—
GA
Enumeration date
04/12/2018
Last updated
06/16/2018
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