Provider Demographics
NPI:1972161768
Name:HENRY, ANDREA NICOLE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:HENRY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:TUTTOLOMONDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:1201 BURLEYSON ROAD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720
Mailing Address - Country:US
Mailing Address - Phone:706-226-8900
Mailing Address - Fax:
Practice Address - Street 1:1201 BURLEYSON ROAD, DALTON, GA. 30720
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720
Practice Address - Country:US
Practice Address - Phone:706-226-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist