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General NPI Number Information
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NPI Number | 1083439681
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Entity Type | Individual
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Provider Name | DELISE ROSE BRAVO-BUSSEY CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 11/19/2024
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Last Update Date | 11/19/2024
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Provider Practice Location Address
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Address Line | 100 N 3RD AVE STE B
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City | CHATSWORTH
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State | GA
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Zip | 30705-2942
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Country | US
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Telephone | 843-540-2494
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Fax | 478-845-2863
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Provider Business Mailing Address
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Address Line | 612 GI MADDOX PKWY
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City | CHATSWORTH
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State | GA
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Zip | 30705-2079
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Country | US
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Telephone |
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Fax |
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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 | SLP008257
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License Number State | GA
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