Provider Demographics
NPI:1699852921
Name:BASSETT, MARCIA B (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:B
Last Name:BASSETT
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:912 KILLIAN HILL RD SW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3138
Mailing Address - Country:US
Mailing Address - Phone:770-638-7200
Mailing Address - Fax:770-638-7265
Practice Address - Street 1:912 KILLIAN HILL RD SW
Practice Address - Street 2:SUITE 103
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3138
Practice Address - Country:US
Practice Address - Phone:770-638-7200
Practice Address - Fax:770-638-7265
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004073235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52172948001OtherBLUE CROSS
GA331761OtherWELLCARE
GA10054033OtherAMERIGROUP
GA11541610OtherCAQH
GA7395784OtherAETNA