Provider Demographics
NPI:1871152009
Name:SUMRALL, RAELYN JO
Entity type:Individual
Prefix:
First Name:RAELYN
Middle Name:JO
Last Name:SUMRALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAELYN
Other - Middle Name:JO
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:214 ADAMS CT
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3819
Mailing Address - Country:US
Mailing Address - Phone:912-486-0646
Mailing Address - Fax:
Practice Address - Street 1:1013 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-4313
Practice Address - Country:US
Practice Address - Phone:478-224-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010651235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist