1376162479 NPI number — MARIAM MOLDENHAUER M.A.

Table of content: MARIAM MOLDENHAUER M.A. (NPI 1376162479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376162479 NPI number — MARIAM MOLDENHAUER M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLDENHAUER
Provider First Name:
MARIAM
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TURNER
Provider Other First Name:
MARIAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376162479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 PEACHTREE RD STE C120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DORAVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30360-3234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-514-3270
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6035 PEACHTREE RD STE C1206035
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DORAVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30360-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-410-7719
Provider Business Practice Location Address Fax Number:
770-410-9510
Provider Enumeration Date:
04/09/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP010986 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003232001C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003232001B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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