Provider Demographics
NPI:1124261938
Name:WALDREP, DIANA GODWIN (SLP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:GODWIN
Last Name:WALDREP
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 RIVERBURCH PKWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721-8887
Mailing Address - Country:US
Mailing Address - Phone:866-261-8090
Mailing Address - Fax:
Practice Address - Street 1:1013 RIVERBURCH PKWY
Practice Address - Street 2:SUITE 4
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30721-8887
Practice Address - Country:US
Practice Address - Phone:866-261-8090
Practice Address - Fax:706-226-7869
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET001409235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist