Provider Demographics
NPI:1215232335
Name:GARDNER, MARY GRACE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GRACE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4116 ARKWRIGHT RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1707
Mailing Address - Country:US
Mailing Address - Phone:478-477-0601
Mailing Address - Fax:973-965-4580
Practice Address - Street 1:4116 ARKWRIGHT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1707
Practice Address - Country:US
Practice Address - Phone:478-477-0601
Practice Address - Fax:973-965-4580
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007411235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist