Provider Demographics
NPI:1043445737
Name:KLINK, LORI JILL (SLP)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JILL
Last Name:KLINK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5426 AMBER COVE WAY
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5737
Mailing Address - Country:US
Mailing Address - Phone:770-967-0136
Mailing Address - Fax:
Practice Address - Street 1:5426 AMBER COVE WAY
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5737
Practice Address - Country:US
Practice Address - Phone:770-967-0136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-25
Last Update Date:2009-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA435161759BMedicaid