Provider Demographics
NPI:1497748586
Name:PRICE, KAREN DETLEFSEN (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:DETLEFSEN
Last Name:PRICE
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 IVY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3119
Mailing Address - Country:US
Mailing Address - Phone:404-883-6913
Mailing Address - Fax:
Practice Address - Street 1:200 IVY CREEK DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3119
Practice Address - Country:US
Practice Address - Phone:404-883-6913
Practice Address - Fax:770-554-0156
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000785793BMedicaid