Provider Demographics
NPI:1306241450
Name:SPEECH SPA, LLC.
Entity type:Organization
Organization Name:SPEECH SPA, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:COLEMANPERRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:678-825-5750
Mailing Address - Street 1:5826 RUE VILLA LN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-1966
Mailing Address - Country:US
Mailing Address - Phone:678-825-5750
Mailing Address - Fax:
Practice Address - Street 1:2260 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4036
Practice Address - Country:US
Practice Address - Phone:678-825-5750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008019252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003131271CMedicaid