Provider Demographics
NPI:1669628335
Name:MOLAND, RENE WYSOCKI (AUD)
Entity Type:Individual
Prefix:MRS
First Name:RENE
Middle Name:WYSOCKI
Last Name:MOLAND
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MISS
Other - First Name:RENE
Other - Middle Name:NOEL
Other - Last Name:WYSOCKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:980 JOHNSON FERRY ROAD
Mailing Address - Street 2:SUITE 470
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-851-9093
Mailing Address - Fax:404-851-9097
Practice Address - Street 1:980 JOHNSON FERRY ROAD
Practice Address - Street 2:SUITE 470
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-851-9093
Practice Address - Fax:404-851-9097
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001301231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA001301OtherAUDIOLOGY LICENSE