Provider Demographics
NPI:1053199489
Name:BRADLEY-GRIFFIN, DESIA
Entity type:Individual
Prefix:
First Name:DESIA
Middle Name:
Last Name:BRADLEY-GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 CHARLESTON PL
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6424
Mailing Address - Country:US
Mailing Address - Phone:585-230-9151
Mailing Address - Fax:
Practice Address - Street 1:1329 CHARLESTON PL
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6424
Practice Address - Country:US
Practice Address - Phone:585-230-9151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist