Provider Demographics
NPI:1598831729
Name:WORTHINGTON, LAURA L (MCD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 WATERS EDGE LN
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-3594
Mailing Address - Country:US
Mailing Address - Phone:770-251-1869
Mailing Address - Fax:706-378-9046
Practice Address - Street 1:225 WATERS EDGE LN
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-3594
Practice Address - Country:US
Practice Address - Phone:770-251-1869
Practice Address - Fax:706-378-9046
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004676235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000866269BMedicaid
GA000866269DMedicaid