Provider Demographics
NPI:1295116267
Name:ANDERSON, MABLE
Entity type:Individual
Prefix:
First Name:MABLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1818
Mailing Address - Country:US
Mailing Address - Phone:478-361-4252
Mailing Address - Fax:
Practice Address - Street 1:946 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1818
Practice Address - Country:US
Practice Address - Phone:478-361-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP001945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist