Provider Demographics
NPI:1154858207
Name:FORTSON, CHANDLER (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHANDLER
Middle Name:
Last Name:FORTSON
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 1:204 RESOURCE LN
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-8361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 RESOURCE LN
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-8361
Practice Address - Country:US
Practice Address - Phone:678-963-0694
Practice Address - Fax:888-547-4008
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009636235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist