Provider Demographics
NPI:1861686016
Name:PRENDERGAST, TAMIKA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:PRENDERGAST
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 1:166 WATERCRESS CT
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7261
Mailing Address - Country:US
Mailing Address - Phone:404-474-1627
Mailing Address - Fax:404-474-8937
Practice Address - Street 1:166 WATERCRESS CT
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7261
Practice Address - Country:US
Practice Address - Phone:404-474-1627
Practice Address - Fax:404-474-8937
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006706235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA503288327BMedicaid