Healthcare Provider Details

I. General information

NPI: 1093875841
Provider Name (Legal Business Name): SANDRA S WHITE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 SEMINOLE AVE NE SUITE T05
ATLANTA GA
30307
US

IV. Provider business mailing address

675 SEMINOLE AVE NE SUITE T05
ATLANTA GA
30307
US

V. Phone/Fax

Practice location:
  • Phone: 404-575-4000
  • Fax: 404-575-4010
Mailing address:
  • Phone: 404-575-4000
  • Fax: 404-575-4010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP 006503
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: