Provider Demographics
NPI:1376747428
Name:SMALL-BURNAM, TAWNY CRYSTAL (SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAWNY
Middle Name:CRYSTAL
Last Name:SMALL-BURNAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:MISS
Other - First Name:TAWNY
Other - Middle Name:CRYSTAL
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6886 MAIN ST STE 1B2
Mailing Address - Street 2:BOX 4
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4508
Mailing Address - Country:US
Mailing Address - Phone:770-367-4241
Mailing Address - Fax:
Practice Address - Street 1:6886 MAIN ST STE 1B2
Practice Address - Street 2:BOX 4
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4508
Practice Address - Country:US
Practice Address - Phone:770-367-4241
Practice Address - Fax:770-482-9401
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051314571OtherDRIVERS LICENSE