Provider Demographics
NPI:1891215547
Name:BARTOLOTTA, THERESA (PHD, CCC-SLP)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:BARTOLOTTA
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 MUSKOGEE LN
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-6003
Mailing Address - Country:US
Mailing Address - Phone:732-580-0283
Mailing Address - Fax:
Practice Address - Street 1:2530 MUSKOGEE LN
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-6003
Practice Address - Country:US
Practice Address - Phone:732-580-0283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010242235Z00000X
NJYS01881235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist