Provider Demographics
NPI:1922679547
Name:STEWART, MARY CHARLES (CF-SLP)
Entity Type:Individual
Prefix:
First Name:MARY CHARLES
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 MIDVALE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3327
Mailing Address - Country:US
Mailing Address - Phone:256-566-4248
Mailing Address - Fax:
Practice Address - Street 1:5825 GLENRIDGE DR STE 1-133
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-7144
Practice Address - Country:US
Practice Address - Phone:678-733-9318
Practice Address - Fax:404-902-5440
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPCET003364OtherPCE TEMPORARY SPEECH-LANGUAGE PATHOLOGY LICENSE