Healthcare Provider Details

I. General information

NPI: 1679499180
Provider Name (Legal Business Name): LORALYE QUEEN M.ED CF-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 S PARK ST STE H
CARROLLTON GA
30117-4456
US

IV. Provider business mailing address

909 S PARK ST STE H
CARROLLTON GA
30117-4456
US

V. Phone/Fax

Practice location:
  • Phone: 678-601-3396
  • Fax: 678-601-3274
Mailing address:
  • Phone: 678-601-3396
  • Fax: 678-601-3274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPCET004549
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: