Provider Demographics
NPI:1528418746
Name:BLAIR, ELIZABETH (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLAIR
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 1:1310 GABLES DR NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 GABLES DR NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30319-5345
Practice Address - Country:US
Practice Address - Phone:404-271-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist