Provider Demographics
NPI:1609152826
Name:CHANCE, CULLEN BROOKE (SLP)
Entity Type:Individual
Prefix:
First Name:CULLEN
Middle Name:BROOKE
Last Name:CHANCE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 GENTILLY RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5149
Mailing Address - Country:US
Mailing Address - Phone:912-681-7768
Mailing Address - Fax:912-681-7782
Practice Address - Street 1:518 GENTILLY RD
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5149
Practice Address - Country:US
Practice Address - Phone:912-681-7768
Practice Address - Fax:912-681-7782
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007483235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist