Provider Demographics
NPI:1730255035
Name:DELOACH, RALPH SMITH III (MED,CCC-SLP)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:SMITH
Last Name:DELOACH
Suffix:III
Gender:M
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3615 BRASELTON HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5906
Mailing Address - Country:US
Mailing Address - Phone:678-377-9634
Mailing Address - Fax:678-377-9609
Practice Address - Street 1:3615 BRASELTON HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5906
Practice Address - Country:US
Practice Address - Phone:678-377-9634
Practice Address - Fax:678-377-9609
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GASLP004677235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10035715Medicaid
GA305500Medicaid
GA52813029-001OtherBCBS PROVIDER ID