Provider Demographics
NPI:1770869364
Name:CEDOR, MARIE ALICE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ALICE
Last Name:CEDOR
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 1:1948 KELVIN DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-3154
Mailing Address - Country:US
Mailing Address - Phone:770-237-2865
Mailing Address - Fax:
Practice Address - Street 1:1948 KELVIN DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-3154
Practice Address - Country:US
Practice Address - Phone:770-237-2865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities