1457696825 NPI number — MRS. MIRYAM BORDOW DACONCEICAO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457696825 NPI number — MRS. MIRYAM BORDOW DACONCEICAO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DACONCEICAO
Provider First Name:
MIRYAM
Provider Middle Name:
BORDOW
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DACONCEICAO
Provider Other First Name:
MIRYAM
Provider Other Middle Name:
BORDWO
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS/CCC/SLP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1457696825
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36261 OKEFENOKEE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOLKSTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31537-7853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-496-7396
Provider Business Mailing Address Fax Number:
912-496-2087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36261 OKEFENOKEE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLKSTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31537-7853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-496-7396
Provider Business Practice Location Address Fax Number:
912-496-2087
Provider Enumeration Date:
12/11/2012

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:  SLP006725 , 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)





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