Provider Demographics
NPI:1598470072
Name:FRATT, CARLIE SANDEFUR (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:SANDEFUR
Last Name:FRATT
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 1:2000 MIRROR LAKE BLVD STE T
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-2126
Mailing Address - Country:US
Mailing Address - Phone:770-783-9797
Mailing Address - Fax:
Practice Address - Street 1:2000 MIRROR LAKE BLVD STE T
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-2126
Practice Address - Country:US
Practice Address - Phone:770-783-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012134235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist