Healthcare Provider Details

I. General information

NPI: 1104194331
Provider Name (Legal Business Name): MARILYN JOHNSON DUNHAM WARK MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN JOHNSON DUNHAM MA CCC-SLP

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 N PARK LOOP
MEMPHIS TN
38152-5042
US

IV. Provider business mailing address

850 POPLAR AVE BLDG 2
MEMPHIS TN
38105-4607
US

V. Phone/Fax

Practice location:
  • Phone: 901-678-2009
  • Fax:
Mailing address:
  • Phone: 901-287-5565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number0000000751
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: