Provider Demographics
NPI:1194266411
Name:FENDERSON, SHYLA (MACCC-SLP)
Entity type:Individual
Prefix:
First Name:SHYLA
Middle Name:
Last Name:FENDERSON
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 HILL CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-2957
Mailing Address - Country:US
Mailing Address - Phone:678-856-1075
Mailing Address - Fax:
Practice Address - Street 1:1550 HILL CROSSING CT
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-2957
Practice Address - Country:US
Practice Address - Phone:678-856-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009571235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist