Provider Demographics
NPI:1053632513
Name:BROWN, MARY ELLEN-MCCORMICK (MS, CCC-SLP, CRDI)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN-MCCORMICK
Last Name:BROWN
Suffix:
Gender:F
Credentials:MS, CCC-SLP, CRDI
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:3292 THOMPSON BRIDGE RD
Mailing Address - Street 2:SUITE 327
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-1561
Mailing Address - Country:US
Mailing Address - Phone:850-345-6010
Mailing Address - Fax:
Practice Address - Street 1:4640 MARTIN RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5542
Practice Address - Country:US
Practice Address - Phone:678-679-1261
Practice Address - Fax:678-250-9010
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007280235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00112935AMedicaid