Provider Demographics
NPI:1407650708
Name:BLACK BRUCE, BRANTLEY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:BRANTLEY
Middle Name:
Last Name:BLACK BRUCE
Suffix:
Gender:
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:BRANTLEY
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:4370 LAUREL GROVE TRCE
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:437 OLD PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2978
Practice Address - Country:US
Practice Address - Phone:678-301-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14173439235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist