Provider Demographics
NPI:1356477061
Name:HOLBERT, LOUISE A (SLP)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:A
Last Name:HOLBERT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 DARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-4895
Mailing Address - Country:US
Mailing Address - Phone:678-485-6239
Mailing Address - Fax:706-243-4269
Practice Address - Street 1:2011 DARWOOD DR
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-4895
Practice Address - Country:US
Practice Address - Phone:678-485-6239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006517235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA755945802BMedicaid