Provider Demographics
NPI:1376162479
Name:MOLDENHAUER, MARIAM (MA)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:MOLDENHAUER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:6035 PEACHTREE RD STE C120
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30360-3234
Mailing Address - Country:US
Mailing Address - Phone:678-514-3270
Mailing Address - Fax:
Practice Address - Street 1:6035 PEACHTREE RD STE C1206035
Practice Address - Street 2:
Practice Address - City:DORAVILLE
Practice Address - State:GA
Practice Address - Zip Code:30360-3230
Practice Address - Country:US
Practice Address - Phone:770-410-7719
Practice Address - Fax:770-410-9510
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010986235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003232001CMedicaid
GA003232001BMedicaid