Basic Information
| Provider Information | |||||||||
| NPI: | 1184018731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SMALL STEPS PEDIATRIC SPEECH THERAPY,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 GABLES DR | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313229693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126676468 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 GABLES DR | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313229693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126676468 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2015 | ||||||||
| LastUpdateDate: | 03/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | DANIELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER-SPEECH PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9126676468 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.ED, CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | SLP008055 | GA | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | 003134193A | 05 | GA | MEDICAID |