{
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"FirstLineMailingAddress": "5928 MONTPELIER DR",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "WILLIAMSBURG",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23188-8122",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "757-345-3329",
"MailingAddressFaxNumber": "757-565-1738",
"FirstLinePracticeLocationAddress": "1769 JAMESTOWN RD",
"SecondLinePracticeLocationAddress": "SUITE 103",
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"EnumerationDate": "07/27/2012",
"LastUpdateDate": "07/27/2012",
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"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BEAVERS",
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"AuthorizedOfficialTitle": "SPEECH LANGUAGE PATHOLOGIST",
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"AuthorizedOfficialCredential": "M.S. CCC-SLP",
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"Taxonomy": {
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"TaxonomyName": "Speech-Language Pathologist",
"LicenseNumber": "2202004986",
"LicenseNumberStateCode": "VA",
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}
},
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}