Provider Demographics
NPI:1063574192
Name:BAERWALDE, ANDREA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:BAERWALDE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 GARLAND ROSE LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-5001
Mailing Address - Country:US
Mailing Address - Phone:770-380-2067
Mailing Address - Fax:770-974-7631
Practice Address - Street 1:71 GARLAND ROSE LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-5001
Practice Address - Country:US
Practice Address - Phone:770-380-2067
Practice Address - Fax:770-974-7631
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist