Healthcare Provider Details

I. General information

NPI: 1215693080
Provider Name (Legal Business Name): MARIYA T SYDOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BUFORD VILLAGE WAY STE 229
BUFORD GA
30518-8846
US

IV. Provider business mailing address

747 RALPH MCGILL BLVD NE UNIT 1256
ATLANTA GA
30312-1136
US

V. Phone/Fax

Practice location:
  • Phone: 470-589-1218
  • Fax:
Mailing address:
  • Phone: 228-731-7505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP012248
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: