Provider Demographics
NPI:1174161624
Name:CRUCIBLE COMMUNICATION THERAPY LLC
Entity type:Organization
Organization Name:CRUCIBLE COMMUNICATION THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:M,ED CCC-SLP
Authorized Official - Phone:770-570-2140
Mailing Address - Street 1:9765 WALNUT GROVE TRAIL
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180
Mailing Address - Country:US
Mailing Address - Phone:770-727-2732
Mailing Address - Fax:
Practice Address - Street 1:9765 WALNUT GROVE TRAIL
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180
Practice Address - Country:US
Practice Address - Phone:770-727-2732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP010654Medicaid