Provider Demographics
NPI:1073092672
Name:PRUSA, ANNA (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:PRUSA
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 TOWEY TRL
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7057
Mailing Address - Country:US
Mailing Address - Phone:770-361-6375
Mailing Address - Fax:
Practice Address - Street 1:137 TOWEY TRL
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7057
Practice Address - Country:US
Practice Address - Phone:770-361-6375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist