Provider Demographics
NPI:1104194331
Name:WARK, MARILYN JOHNSON DUNHAM (MA CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:JOHNSON DUNHAM
Last Name:WARK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:JOHNSON
Other - Last Name:DUNHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:850 POPLAR AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4607
Mailing Address - Country:US
Mailing Address - Phone:901-287-5565
Mailing Address - Fax:
Practice Address - Street 1:4055 N PARK LOOP
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38152-5042
Practice Address - Country:US
Practice Address - Phone:901-678-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000751235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527831Medicaid