Provider Demographics
NPI:1962200378
Name:REDD, NIA
Entity type:Individual
Prefix:
First Name:NIA
Middle Name:
Last Name:REDD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HUNTCLIFF TRL
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2597
Mailing Address - Country:US
Mailing Address - Phone:310-415-9101
Mailing Address - Fax:
Practice Address - Street 1:780 MEMORIAL DR SE APT 622
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-1751
Practice Address - Country:US
Practice Address - Phone:310-415-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist