Provider Demographics
NPI:1629291695
Name:PROHASKA, NANCY A (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:PROHASKA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 DOUBLE CHURCHES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2741
Mailing Address - Country:US
Mailing Address - Phone:270-769-0058
Mailing Address - Fax:
Practice Address - Street 1:2424 DOUBLE CHURCHES RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2741
Practice Address - Country:US
Practice Address - Phone:270-769-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2891235Z00000X
GASLP006994235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116659Medicare Oscar/Certification