Provider Demographics
NPI:1811269442
Name:TERRELL, WALLENDA BROOKE (MED,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:WALLENDA
Middle Name:BROOKE
Last Name:TERRELL
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
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Mailing Address - Street 1:3932 HERRON LN SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-1599
Mailing Address - Country:US
Mailing Address - Phone:678-322-8255
Mailing Address - Fax:888-806-8549
Practice Address - Street 1:1514 CLEVELAND AVE STE 101B
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6965
Practice Address - Country:US
Practice Address - Phone:678-322-8255
Practice Address - Fax:888-806-8549
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GASLP005683235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist