Basic Information
| Provider Information | |||||||||
| NPI: | 1679734024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARNES | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | LARAYNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | SPEECH THERAPIST (MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 F GLENDA TRACE | ||||||||
| Address2: | STE #414 | ||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705029740 | ||||||||
| FaxNumber: | 7706834250 | ||||||||
| Practice Location | |||||||||
| Address1: | 39 ROLLINGBROOK VISTA | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705029740 | ||||||||
| FaxNumber: | 7706834250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 07/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP006883 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 842455980B | 05 | GA | MEDICAID |