Basic Information
| Provider Information | |||||||||
| NPI: | 1366634057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCLENDON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MCD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2424 DOUBLE CHURCHES RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319092741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063246112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2424 DOUBLE CHURCHES RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319092741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063246112 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 08/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SLP006370 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 235900748A | 05 | GA | MEDICAID |