Provider Demographics
NPI:1952825424
Name:BROWN, BLAKELY RAE
Entity Type:Individual
Prefix:MS
First Name:BLAKELY
Middle Name:RAE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W BOLLING RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3152
Mailing Address - Country:US
Mailing Address - Phone:229-347-3212
Mailing Address - Fax:
Practice Address - Street 1:6035 PEACHTREE RD STE C120
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30360-3234
Practice Address - Country:US
Practice Address - Phone:678-514-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009672235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist