Provider Demographics
NPI:1164763967
Name:FARMER, MAVIS
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:
Last Name:FARMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CRESCENT CIR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4772
Mailing Address - Country:US
Mailing Address - Phone:678-462-1342
Mailing Address - Fax:
Practice Address - Street 1:1860 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9117
Practice Address - Country:US
Practice Address - Phone:678-462-1342
Practice Address - Fax:678-493-9464
Is Sole Proprietor?:No
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001844235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist