Provider Demographics
NPI:1861374381
Name:GLOW FORWARD THERAPY, LLC
Entity type:Organization
Organization Name:GLOW FORWARD THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MS, CCC-SLP
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:REID
Authorized Official - Last Name:LEAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-258-6200
Mailing Address - Street 1:1994 TOWNSHIP DR
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-5633
Mailing Address - Country:US
Mailing Address - Phone:252-258-6200
Mailing Address - Fax:
Practice Address - Street 1:1994 TOWNSHIP DR
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-5633
Practice Address - Country:US
Practice Address - Phone:252-258-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty