Provider Demographics
NPI:1821539388
Name:ERNST, BREANNA LAUREN (MED,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:LAUREN
Last Name:ERNST
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 1:175 ROBERTSON CT
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7234
Mailing Address - Country:US
Mailing Address - Phone:678-622-4376
Mailing Address - Fax:
Practice Address - Street 1:175 ROBERTSON CT
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7234
Practice Address - Country:US
Practice Address - Phone:678-622-4376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-16
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist