Provider Demographics
NPI:1093046187
Name:PANTAZIS, THEOFANIS (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:THEOFANIS
Middle Name:
Last Name:PANTAZIS
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 FUTRAL RD
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-7455
Mailing Address - Country:US
Mailing Address - Phone:770-229-5511
Mailing Address - Fax:770-233-0995
Practice Address - Street 1:141 FUTRAL RD
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-7455
Practice Address - Country:US
Practice Address - Phone:770-229-5511
Practice Address - Fax:770-233-0995
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006935235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist