Provider Demographics
NPI:1457696825
Name:DACONCEICAO, MIRYAM BORDOW
Entity type:Individual
Prefix:MRS
First Name:MIRYAM
Middle Name:BORDOW
Last Name:DACONCEICAO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MIRYAM
Other - Middle Name:BORDWO
Other - Last Name:DACONCEICAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS/CCC/SLP
Mailing Address - Street 1:36261 OKEFENOKEE DR
Mailing Address - Street 2:
Mailing Address - City:FOLKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:31537-7853
Mailing Address - Country:US
Mailing Address - Phone:912-496-7396
Mailing Address - Fax:912-496-2087
Practice Address - Street 1:36261 OKEFENOKEE DR
Practice Address - Street 2:
Practice Address - City:FOLKSTON
Practice Address - State:GA
Practice Address - Zip Code:31537-7853
Practice Address - Country:US
Practice Address - Phone:912-496-7396
Practice Address - Fax:912-496-2087
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist