Provider Demographics
NPI:1750514402
Name:MOKHEMAR, MARY ANN (SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:MOKHEMAR
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 CROSSBRIDGE ALY
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7535
Mailing Address - Country:US
Mailing Address - Phone:678-691-5586
Mailing Address - Fax:
Practice Address - Street 1:1200 LAKE HEARN DR NE
Practice Address - Street 2:SUITE 250
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1415
Practice Address - Country:US
Practice Address - Phone:404-943-1070
Practice Address - Fax:404-943-0890
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP000846235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049102267OtherDRIVER LICENSE