Provider Demographics
NPI:1801514948
Name:BENHAM, LORELEI (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LORELEI
Middle Name:
Last Name:BENHAM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 GUNNIN RD
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-1951
Mailing Address - Country:US
Mailing Address - Phone:678-687-0119
Mailing Address - Fax:
Practice Address - Street 1:4151 GUNNIN RD
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-1951
Practice Address - Country:US
Practice Address - Phone:678-687-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009088235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP009088OtherGEORGIA LICENSE
14086292OtherASHA