Healthcare Provider Details

I. General information

NPI: 1538163167
Provider Name (Legal Business Name): PAULINE L KUNTZ SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 SMYRNA RIDGE CT SW
CONYERS GA
30094-6200
US

IV. Provider business mailing address

2160 SMYRNA RIDGE CT SW
CONYERS GA
30094-6200
US

V. Phone/Fax

Practice location:
  • Phone: 770-483-1083
  • Fax: 770-483-1083
Mailing address:
  • Phone: 770-483-1083
  • Fax: 770-483-1083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number000368
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: