Provider Demographics
NPI:1861977001
Name:CANTRELL, LORI ALLYSON
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:ALLYSON
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:DUNAGAN
Other - Last Name:CANTRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:530 BLAIR RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:GA
Mailing Address - Zip Code:30563-3825
Mailing Address - Country:US
Mailing Address - Phone:706-778-0874
Mailing Address - Fax:
Practice Address - Street 1:130 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:GA
Practice Address - Zip Code:30527-1804
Practice Address - Country:US
Practice Address - Phone:678-616-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist