Provider Demographics
NPI:1639621535
Name:DUAN, GEORGIA ANGELA (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:ANGELA
Last Name:DUAN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 REVEREND JAMES A. POLITE AVENUE
Mailing Address - Street 2:PS 333 C/O GEORGIA DUAN
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-4107
Mailing Address - Country:US
Mailing Address - Phone:718-860-3313
Mailing Address - Fax:
Practice Address - Street 1:778 FOREST AVE
Practice Address - Street 2:P17X C/O MAIN OFFICE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-7803
Practice Address - Country:US
Practice Address - Phone:415-868-5423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026248235Z00000X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04578869Medicaid