Provider Demographics
NPI:1215168018
Name:GEORGE, MIRANDA E (MED,CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:E
Last Name:GEORGE
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6000
Mailing Address - Country:US
Mailing Address - Phone:706-378-9044
Mailing Address - Fax:706-378-9046
Practice Address - Street 1:304 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6000
Practice Address - Country:US
Practice Address - Phone:706-378-9044
Practice Address - Fax:706-378-9046
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007129235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist