Provider Demographics
NPI:1114760790
Name:THOMAS, MADELYN GRACE (MED , CF-SLP)
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:GRACE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MED , CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MARINA DR APT 304A
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2254
Mailing Address - Country:US
Mailing Address - Phone:912-381-9092
Mailing Address - Fax:
Practice Address - Street 1:106 SHOPPERS WAY STE 112
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-0522
Practice Address - Country:US
Practice Address - Phone:912-554-3805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET004005235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist