Provider Demographics
NPI:1538228465
Name:DENNISON, LAURA (MA, CCC-A)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DENNISON
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 LAWRENCEVILLE HWY.
Mailing Address - Street 2:STE. 10A
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30044
Mailing Address - Country:US
Mailing Address - Phone:770-717-5711
Mailing Address - Fax:770-717-5612
Practice Address - Street 1:4145 LAWRENCEVILLE HWY.
Practice Address - Street 2:STE. 10A
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30044
Practice Address - Country:US
Practice Address - Phone:770-717-5711
Practice Address - Fax:770-717-5612
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00373029CMedicaid
GA00668533CMedicaid
GA00373029CMedicaid