Provider Demographics
NPI:1386465045
Name:SOUTHPORT SPEECH AND LANGUAGE, PLLC
Entity type:Organization
Organization Name:SOUTHPORT SPEECH AND LANGUAGE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ANN MCDANIEL
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:336-404-4802
Mailing Address - Street 1:1746 E CORONADO AVE SE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-0900
Mailing Address - Country:US
Mailing Address - Phone:336-404-4802
Mailing Address - Fax:
Practice Address - Street 1:1746 E CORONADO AVE SE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-0900
Practice Address - Country:US
Practice Address - Phone:336-404-4802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1740839695OtherNPI
NC14966OtherSTATE
NC7413660Medicaid