MEDICARE: MRS. WALLENDA BROOKE TERRELL M.ED.,CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SLP005683	GA

General Provider Information

NPI Number	:	1811269442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WALLENDA BROOKE TERRELL M.ED.,CCC-SLP

Provider Business Mailing Address
First Line	:	3932 HERRON LN SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-1599
Country	:	US
Telephone Number	:	678-322-8255
Fax Number	:	888-806-8549

Provider Business Practice Location Address
First Line	:	1514 CLEVELAND AVE STE 101B
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-6965
Country	:	US
Telephone Number	:	678-322-8255
Fax Number	:	888-806-8549

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2012
Last Update Date	:	11/28/2018

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