Provider Demographics
NPI:1649680141
Name:FUNDAMENTAL SPEECH THERAPY SERVICES INC.
Entity type:Organization
Organization Name:FUNDAMENTAL SPEECH THERAPY SERVICES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LABRITA
Authorized Official - Middle Name:JEANENE
Authorized Official - Last Name:CASH-BASKETT
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:770-317-5993
Mailing Address - Street 1:1015 BRIDGE MILL AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7797
Mailing Address - Country:US
Mailing Address - Phone:770-317-5993
Mailing Address - Fax:
Practice Address - Street 1:2562 FAIRBURN RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1461
Practice Address - Country:US
Practice Address - Phone:770-317-5993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FUNDAMENTAL SPEECH THERAPY SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0005319261QA3000X, 261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QA3000XAmbulatory Health Care FacilitiesClinic/CenterAugmentative Communication