=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679734024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE LARAYNE BARNES SPEECH THERAPIST (MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2008
-----------------------------------------------------
Last Update Date | 07/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 ROLLINGBROOK VISTA
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-502-9740
-----------------------------------------------------
Fax | 770-683-4250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 F GLENDA TRACE STE #414
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-502-9740
-----------------------------------------------------
Fax | 770-683-4250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP006883
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------