Provider Demographics
NPI:1629354568
Name:BENNETT, JANICE LEIGH ANNE (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:LEIGH ANNE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:LEIGH ANNE
Other - Last Name:GRIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED CCC-SLP
Mailing Address - Street 1:1006 SCOTLAND RD
Mailing Address - Street 2:
Mailing Address - City:RENTZ
Mailing Address - State:GA
Mailing Address - Zip Code:31075-3316
Mailing Address - Country:US
Mailing Address - Phone:478-272-2100
Mailing Address - Fax:478-272-2005
Practice Address - Street 1:1205 BELLEVUE AVE
Practice Address - Street 2:SUITE H
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-4155
Practice Address - Country:US
Practice Address - Phone:478-272-2100
Practice Address - Fax:478-272-2005
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1770843948OtherNPI GROUP
GA003126629AMedicaid
GA1770843948OtherNPI GROUP