Provider Demographics
NPI:1013901156
Name:THISDALE, KENNETH ALLEN (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALLEN
Last Name:THISDALE
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:948 WOOD DUCK CT
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-7728
Mailing Address - Country:US
Mailing Address - Phone:404-964-7808
Mailing Address - Fax:770-982-2247
Practice Address - Street 1:948 WOOD DUCK CT
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7728
Practice Address - Country:US
Practice Address - Phone:404-964-7808
Practice Address - Fax:770-982-2247
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist