Provider Demographics
NPI:1215368089
Name:HALES, HOLLY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:HALES
Suffix:
Gender:F
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 1:108 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:GA
Mailing Address - Zip Code:31302-8535
Mailing Address - Country:US
Mailing Address - Phone:912-658-6433
Mailing Address - Fax:
Practice Address - Street 1:108 WALNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:GA
Practice Address - Zip Code:31302-8535
Practice Address - Country:US
Practice Address - Phone:912-658-6433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1189302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist