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General NPI Number Information
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NPI Number | 1013901156
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Entity Type | Individual
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Provider Name | KENNETH ALLEN THISDALE M.A., CCC-SLP
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Gender | Male
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Dates
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Enumeration Date | 09/06/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 948 WOOD DUCK CT
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City | SNELLVILLE
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State | GA
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Zip | 30078-7728
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Country | US
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Telephone | 404-964-7808
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Fax | 770-982-2247
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Provider Business Mailing Address
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Address Line | 948 WOOD DUCK CT
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City | SNELLVILLE
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State | GA
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Zip | 30078-7728
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Country | US
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Telephone | 404-964-7808
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Fax | 770-982-2247
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP003500
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License Number State | GA
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