Provider Demographics
NPI:1902497506
Name:GEORGIA INSTITUTE OF SPEECH AND LANGUAGE
Entity Type:Organization
Organization Name:GEORGIA INSTITUTE OF SPEECH AND LANGUAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:301-825-4201
Mailing Address - Street 1:112 RADCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8371
Mailing Address - Country:US
Mailing Address - Phone:301-825-4201
Mailing Address - Fax:
Practice Address - Street 1:112 RADCLIFFE DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8371
Practice Address - Country:US
Practice Address - Phone:301-825-4201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-27
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty