Provider Demographics
NPI:1285735316
Name:DELLARIA, NANCY BROADHURST (MED CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:BROADHURST
Last Name:DELLARIA
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 RIVER BOTTOM CIR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1992
Mailing Address - Country:US
Mailing Address - Phone:706-548-5773
Mailing Address - Fax:
Practice Address - Street 1:110 CARLTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-5004
Practice Address - Country:US
Practice Address - Phone:706-542-4594
Practice Address - Fax:706-542-4574
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000999235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000999OtherLICENSE