Healthcare Provider Details

I. General information

NPI: 1922467893
Provider Name (Legal Business Name): MESA MILLER CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MESA MILLER ALDRICH CCC-SLP

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 KURT DR
MACON GA
31204-5635
US

IV. Provider business mailing address

4060 KURT DR
MACON GA
31204-5635
US

V. Phone/Fax

Practice location:
  • Phone: 478-747-5197
  • Fax:
Mailing address:
  • Phone: 478-747-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5621
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number28711
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA15263
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP009162
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: