Provider Demographics
NPI:1326045006
Name:GIESBRECHT, MARY KATHLEEN (SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:GIESBRECHT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 LAKE VIEW CT
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-7809
Mailing Address - Country:US
Mailing Address - Phone:912-617-1037
Mailing Address - Fax:912-576-2708
Practice Address - Street 1:102 LAKE VIEW CT
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-7809
Practice Address - Country:US
Practice Address - Phone:912-617-1037
Practice Address - Fax:912-576-2708
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA524841136CMedicaid
GA524841136AMedicaid