Provider Demographics
NPI:1215693080
Name:SYDOW, MARIYA T
Entity type:Individual
Prefix:
First Name:MARIYA
Middle Name:T
Last Name:SYDOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 BROOKTON LULA RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-2909
Mailing Address - Country:US
Mailing Address - Phone:770-983-3221
Mailing Address - Fax:
Practice Address - Street 1:604 WASHINGTON ST NW STE B2
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-8545
Practice Address - Country:US
Practice Address - Phone:770-534-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003393235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist