Provider Demographics
NPI:1376729285
Name:BROWN, GENELLE MCDONALD (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GENELLE
Middle Name:MCDONALD
Last Name:BROWN
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:PO BOX 8259
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-8259
Mailing Address - Country:US
Mailing Address - Phone:478-275-8844
Mailing Address - Fax:478-275-2365
Practice Address - Street 1:806 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-6306
Practice Address - Country:US
Practice Address - Phone:478-275-8844
Practice Address - Fax:478-275-2365
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00926164AMedicaid