Provider Demographics
NPI:1902127343
Name:BASKETT, LAURA COLLEEN (AUD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:COLLEEN
Last Name:BASKETT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:COLLEEN
Other - Last Name:KNUPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:181 UPPER RIVERDALE RD SW STE 1
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4919
Mailing Address - Country:US
Mailing Address - Phone:770-996-2861
Mailing Address - Fax:
Practice Address - Street 1:181 UPPER RIVERDALE RD SW STE 1
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4919
Practice Address - Country:US
Practice Address - Phone:770-996-2861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003842231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist