Provider Demographics
NPI:1164899076
Name:PROSE, JOANNA CHANLETT (SLP-CF (CCC PENDING))
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:CHANLETT
Last Name:PROSE
Suffix:
Gender:F
Credentials:SLP-CF (CCC PENDING)
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:CHANLETT
Other - Last Name:PROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4328 PIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5272
Mailing Address - Country:US
Mailing Address - Phone:919-824-1534
Mailing Address - Fax:
Practice Address - Street 1:4328 PIN OAK DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5272
Practice Address - Country:US
Practice Address - Phone:919-824-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11611235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist