Provider Demographics
NPI:1154408607
Name:SALLY RAY MILLER PIDGE
Entity type:Organization
Organization Name:SALLY RAY MILLER PIDGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:PIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MED CCC-SLP
Authorized Official - Phone:704-708-8314
Mailing Address - Street 1:2301 CROWN POINT EXECUTIVE DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-6725
Mailing Address - Country:US
Mailing Address - Phone:704-708-8314
Mailing Address - Fax:704-708-8315
Practice Address - Street 1:2301 CROWN POINT EXECUTIVE DR
Practice Address - Street 2:SUITE E
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-6725
Practice Address - Country:US
Practice Address - Phone:704-708-8314
Practice Address - Fax:704-708-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4234174400000X
NC2583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411122Medicaid