Basic Information
| Provider Information | |||||||||
| NPI: | 1548219652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIDGE | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10800 INDEPENDENCE POINTE PKWY | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281051753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047088314 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10800 INDEPENDENCE POINTE PKWY | ||||||||
| Address2: | SUITE D | ||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281051753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047088314 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | NC2583 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7411122 | 05 | NC | MEDICAID |