Provider Demographics
NPI:1750810719
Name:PORTE, CORINNE IDA (SLP)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:IDA
Last Name:PORTE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:
Other - Last Name:LACEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:3347 CAMENS WAY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-6755
Mailing Address - Country:US
Mailing Address - Phone:770-653-5175
Mailing Address - Fax:
Practice Address - Street 1:4319 SOUTH LEE STREET
Practice Address - Street 2:CHANDLER SPEECH AND LANGUAGE SERVICES
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-5747
Practice Address - Country:US
Practice Address - Phone:678-288-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist