Provider Demographics
NPI:1588743017
Name:KIEFER, DEIDRE D (MS/CCC/SLP/L)
Entity type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:D
Last Name:KIEFER
Suffix:
Gender:F
Credentials:MS/CCC/SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4142 MENLO DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2225
Mailing Address - Country:US
Mailing Address - Phone:770-939-8547
Mailing Address - Fax:770-939-8769
Practice Address - Street 1:2386 CLOWER ST
Practice Address - Street 2:BUILD. E, SUITE 102
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6134
Practice Address - Country:US
Practice Address - Phone:770-985-9050
Practice Address - Fax:770-985-9223
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00816868AMedicaid