Provider Demographics
NPI:1417532938
Name:DURHAM, LAURA LEE (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:DURHAM
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 1:300 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6934
Mailing Address - Country:US
Mailing Address - Phone:229-985-2080
Mailing Address - Fax:229-890-3397
Practice Address - Street 1:300 SUNSET CIR
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6934
Practice Address - Country:US
Practice Address - Phone:229-985-2080
Practice Address - Fax:229-890-3397
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP011411OtherSPEECH LANGUAGE PATHOLOGIST