Mary L. Duncan, CLINSCD CCC-SLP

Primary specialty

Speech-Language PathologistTaxonomy code 235Z00000X

License

6225 Issued in GA

Practice address

4549 Revenue TRL
Ellenwood, GA 30294-6413

Phone

(404) 805-2875

Fax

(404) 738-2128

NPI assigned

Dec 27, 2006

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Clesiaventures

  • Early Intervention Provider Agency
  • Stockbridge, GA
  • NPI 1952614844
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167177600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623283200000",
    "number": "1669537643",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4549 REVENUE TRL",
            "city": "ELLENWOOD",
            "state": "GA",
            "postal_code": "302946413",
            "telephone_number": "404-805-2875",
            "fax_number": "866-925-7840"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4549 REVENUE TRL",
            "city": "ELLENWOOD",
            "state": "GA",
            "postal_code": "302946413",
            "telephone_number": "404-805-2875",
            "fax_number": "404-738-2128"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "7454 Hannover Pkwy S",
            "address_purpose": "LOCATION",
            "city": "Stockbridge",
            "state": "GA",
            "postal_code": "302817889",
            "country_code": "US",
            "telephone_number": "229-598-6660",
            "fax_number": "404-738-2128",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DUNCAN",
        "first_name": "MARY",
        "middle_name": "L.",
        "name_prefix": "Dr.",
        "credential": "CLINSCD CCC-SLP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2006-12-27",
        "last_updated": "2021-06-10",
        "certification_date": "2021-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "VA",
            "license": "2202009271",
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "IL",
            "license": "146.011397",
            "primary": false
        },
        {
            "code": "235Z00000X",
            "taxonomy_group": "",
            "desc": "Speech-Language Pathologist",
            "state": "GA",
            "license": "6225",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410111878F",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "410111878A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Speech-Language Pathologist in Ellenwood, GA
• Providers in Ellenwood, GA by specialty
• Speech-Language Pathologist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.