Provider Demographics
NPI:1518020981
Name:HARRELSON, HOLLIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:
Last Name:HARRELSON
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 1:5 MUSCADINE DR
Mailing Address - Street 2:
Mailing Address - City:MC RAE HELENA
Mailing Address - State:GA
Mailing Address - Zip Code:31037-4039
Mailing Address - Country:US
Mailing Address - Phone:229-315-1108
Mailing Address - Fax:229-868-5894
Practice Address - Street 1:12 E OAK ST
Practice Address - Street 2:
Practice Address - City:MC RAE HELENA
Practice Address - State:GA
Practice Address - Zip Code:31055-4337
Practice Address - Country:US
Practice Address - Phone:229-315-1108
Practice Address - Fax:229-868-5894
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006542235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA265969642AMedicaid