Basic Information
| Provider Information | |||||||||
| NPI: | 1376137067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 PEACHTREE CIR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303093206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044019250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5461 MERIDIAN MARK RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303423009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045911884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2021 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AUD004261 | GA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | AUD004261 | 01 | GA | GEORGIA AUDIOLOGY LICENSE | OTHER |