1629354568 NPI number — JANICE LEIGH ANNE BENNETT M.ED CCC-SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629354568 NPI number — JANICE LEIGH ANNE BENNETT M.ED CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNETT
Provider First Name:
JANICE
Provider Middle Name:
LEIGH ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRIGGS
Provider Other First Name:
JANICE
Provider Other Middle Name:
LEIGH ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.ED CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629354568
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1006 SCOTLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENTZ
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31075-3316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-272-2100
Provider Business Mailing Address Fax Number:
478-272-2005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 BELLEVUE AVE
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31021-4155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-272-2100
Provider Business Practice Location Address Fax Number:
478-272-2005
Provider Enumeration Date:
10/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP007724 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1770843948 . This is a "NPI GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003126629A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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