Provider Demographics
NPI:1649419821
Name:DOUGLAS, CARMEN MELTON (MED)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:MELTON
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1415 HIGHWAY 85 N
Mailing Address - Street 2:# 310-172
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7738
Mailing Address - Country:US
Mailing Address - Phone:404-317-4140
Mailing Address - Fax:770-603-9072
Practice Address - Street 1:10354 SHEPPERTON COURT
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238
Practice Address - Country:US
Practice Address - Phone:404-317-4140
Practice Address - Fax:770-603-9072
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-12
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000946558DMedicaid