Provider Demographics
NPI:1700084902
Name:GIGNILLIAT, CARLA JEAN (MA, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:CARLA
Middle Name:JEAN
Last Name:GIGNILLIAT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1967 LAKESIDE PKWY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5867
Mailing Address - Country:US
Mailing Address - Phone:770-414-0055
Mailing Address - Fax:
Practice Address - Street 1:1967 LAKESIDE PKWY
Practice Address - Street 2:SUITE 420
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5867
Practice Address - Country:US
Practice Address - Phone:770-414-0055
Practice Address - Fax:770-414-0045
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005592235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA331791073BMedicaid