1669537643 NPI number — DR. MARY L. DUNCAN CLINSCD CCC-SLP

Table of content: DR. MARY L. DUNCAN CLINSCD CCC-SLP (NPI 1669537643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669537643 NPI number — DR. MARY L. DUNCAN CLINSCD CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUNCAN
Provider First Name:
MARY
Provider Middle Name:
L.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
CLINSCD CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669537643
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4549 REVENUE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLENWOOD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30294-6413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-805-2875
Provider Business Mailing Address Fax Number:
866-925-7840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4549 REVENUE TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENWOOD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30294-6413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-805-2875
Provider Business Practice Location Address Fax Number:
404-738-2128
Provider Enumeration Date:
12/27/2006

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:  2202009271 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 146.011397 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: 6225 , 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: 410111878F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410111878A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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