Provider Demographics
NPI:1235669193
Name:WALLS, ANGELA MARIE (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:MARIE
Last Name:WALLS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 SHELDON DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4213
Mailing Address - Country:US
Mailing Address - Phone:404-695-0071
Mailing Address - Fax:
Practice Address - Street 1:5375 FIVE FORKS TRICKUM RD SW
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6746
Practice Address - Country:US
Practice Address - Phone:470-545-6228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009659235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty