Provider Demographics
NPI:1699846766
Name:PHILLIPS, DEMETRIA L (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:L
Last Name:PHILLIPS
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 1:2623 WHISPERING PINES DR
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-2859
Mailing Address - Country:US
Mailing Address - Phone:770-875-2331
Mailing Address - Fax:770-978-0077
Practice Address - Street 1:2623 WHISPERING PINES DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-2859
Practice Address - Country:US
Practice Address - Phone:770-875-2331
Practice Address - Fax:770-978-0077
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA12038676OtherASHA #
GASLP005115OtherGA STATE LICENSE
GA10037022Medicaid
GA305510Medicaid