Provider Demographics
NPI:1063778710
Name:ROBINSON, LATERRIAN MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LATERRIAN
Middle Name:MARIE
Last Name:ROBINSON
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 1:115 BOWEN WAY
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-3434
Mailing Address - Country:US
Mailing Address - Phone:205-602-2337
Mailing Address - Fax:
Practice Address - Street 1:2395 WALL ST SE
Practice Address - Street 2:STE 170
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6703
Practice Address - Country:US
Practice Address - Phone:205-602-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007761235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003123817BMedicaid