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General NPI Number Information
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NPI Number | 1952614844
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Entity Type | Organization
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Legal Business Name | CLESIAVENTURES
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Dates
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Enumeration Date | 07/20/2010
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Last Update Date | 09/20/2021
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Provider Practice Location Address
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Address Line | 7454 HANNOVER PKWY S STE 235
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-6866
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Country | US
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Telephone | 470-491-7707
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Fax | 404-738-2128
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Provider Business Mailing Address
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Address Line | 2330 KENNESAW OAKS CT NW
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City | KENNESAW
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State | GA
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Zip | 30152-4269
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Country | US
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Telephone | 866-925-7840
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Fax | 866-925-7840
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Authorized Official
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Title or Position | SPEECH PATHOLOGIST
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Name | DR. MARY LOUISE DUNCAN
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Credential | M.A. CCC-SLP
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Telephone | 404-805-2875
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | SLP006225
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License Number State | GA
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