Provider Demographics
NPI:1902969298
Name:MCDONALD, MELVENIA (SLP)
Entity Type:Individual
Prefix:MISS
First Name:MELVENIA
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 CARY DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-6510
Mailing Address - Country:US
Mailing Address - Phone:770-760-0406
Mailing Address - Fax:770-760-9047
Practice Address - Street 1:4404 CARY DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-6510
Practice Address - Country:US
Practice Address - Phone:770-760-0406
Practice Address - Fax:770-760-9047
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003002235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000626337DMedicaid