Provider Demographics
NPI:1851543490
Name:MULLIS, HEATHER (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:MULLIS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4370 SATELLITE BLVD APT 620
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4060
Mailing Address - Country:US
Mailing Address - Phone:678-858-4777
Mailing Address - Fax:678-985-3953
Practice Address - Street 1:65 DARCEE CT
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7402
Practice Address - Country:US
Practice Address - Phone:678-858-4777
Practice Address - Fax:678-985-3953
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6927235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA226858618AMedicaid