Healthcare Provider Details

I. General information

NPI: 1093847147
Provider Name (Legal Business Name): MARY SPRAGUE MED. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 CLIFTON ROAD NORTH EAST
ATLANTA GA
30032
US

IV. Provider business mailing address

335 WOODSTREAM DR
NEWNAN GA
30265-1944
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-5512
  • Fax: 404-712-5974
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP006124
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: