Basic Information
| Provider Information | |||||||||
| NPI: | 1770124562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAMBLEE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED., CF-SLP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CHAMBLEE | ||||||||
| OtherFirstName: | DAN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 185 MOSBY WOODS DR | ||||||||
| Address2: | |||||||||
| City: | NEWNAN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302652209 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 747 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | GRIFFIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302244884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702296498 | ||||||||
| FaxNumber: | 7702296958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2019 | ||||||||
| LastUpdateDate: | 03/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | PCET003036 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.