Provider Demographics
NPI:1356429401
Name:BRATHWAITE, CHARLOTTE C (SLP)
Entity type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:C
Last Name:BRATHWAITE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-6503
Mailing Address - Country:US
Mailing Address - Phone:706-868-8686
Mailing Address - Fax:706-868-8643
Practice Address - Street 1:2906 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-6503
Practice Address - Country:US
Practice Address - Phone:706-868-8686
Practice Address - Fax:706-868-8643
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001639235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10065241OtherAMERIGROUP
GA312243OtherWELLCARE