Provider Demographics
NPI:1952614844
Name:CLESIAVENTURES
Entity Type:Organization
Organization Name:CLESIAVENTURES
Other - Org Name:CLESIASPEECH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:404-805-2875
Mailing Address - Street 1:2330 KENNESAW OAKS CT NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-4269
Mailing Address - Country:US
Mailing Address - Phone:866-925-7840
Mailing Address - Fax:866-925-7840
Practice Address - Street 1:7454 HANNOVER PKWY S STE 235
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6866
Practice Address - Country:US
Practice Address - Phone:470-491-7707
Practice Address - Fax:404-738-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006225252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA410111878AMedicaid