Healthcare Provider Details

I. General information

NPI: 1003747874
Provider Name (Legal Business Name): BRYN RICHMOND CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N 3RD AVE STE B
CHATSWORTH GA
30705-2942
US

IV. Provider business mailing address

612 GI MADDOX PKWY
CHATSWORTH GA
30705-2079
US

V. Phone/Fax

Practice location:
  • Phone: 843-540-2494
  • Fax:
Mailing address:
  • Phone: 843-540-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP014124
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: