Provider Demographics
NPI:1063887081
Name:STEWART, SALLY BLAKELY (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:BLAKELY
Last Name:STEWART
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 COVENTRY RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-5229
Mailing Address - Country:US
Mailing Address - Phone:706-255-3415
Mailing Address - Fax:
Practice Address - Street 1:242 KING AVE
Practice Address - Street 2:FIRST FLOOR, MEDICAL SERVICES BUILDING
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist