Provider Demographics
NPI:1205288743
Name:THOMAS, ANSLEY MYRICK (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ANSLEY
Middle Name:MYRICK
Last Name:THOMAS
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 1:1737 GRAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-4863
Mailing Address - Country:US
Mailing Address - Phone:404-402-2579
Mailing Address - Fax:
Practice Address - Street 1:1737 GRAND OAKS DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-4863
Practice Address - Country:US
Practice Address - Phone:404-402-2579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007540235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist