Provider Demographics
NPI:1174737407
Name:WILCOX, MIRIAM HOPE WHATLEY (MCD, CCC-A)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:HOPE WHATLEY
Last Name:WILCOX
Suffix:
Gender:F
Credentials:MCD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 WINDY HILL RD SE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8665
Mailing Address - Country:US
Mailing Address - Phone:770-953-1414
Mailing Address - Fax:770-953-9474
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:SUITE 307
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:770-953-1414
Practice Address - Fax:770-953-9474
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003569AUD231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003569AUDOtherLICENSE