Provider Demographics
NPI:1568453595
Name:LENOIR-MONROE, IDA RACHERYL (EDS,CCC,SLP)
Entity Type:Individual
Prefix:MS
First Name:IDA
Middle Name:RACHERYL
Last Name:LENOIR-MONROE
Suffix:
Gender:F
Credentials:EDS,CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 AUGHTON CT
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-7410
Mailing Address - Country:US
Mailing Address - Phone:770-679-0909
Mailing Address - Fax:
Practice Address - Street 1:1505 AUGHTON CT
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-7410
Practice Address - Country:US
Practice Address - Phone:770-679-0909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3007235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05378356Medicaid