Provider Demographics
NPI:1699550301
Name:MEDEROS, CHRISTINE MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:MEDEROS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3295 RIVER EXCHANGE DR STE 170
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:678-691-2882
Practice Address - Street 1:3295 RIVER EXCHANGE DR STE 170
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-4220
Practice Address - Country:US
Practice Address - Phone:770-862-6447
Practice Address - Fax:678-691-2882
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty