Provider Demographics
NPI:1033609409
Name:STEWART, ANNA VICTORIA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:VICTORIA
Last Name:STEWART
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11790 PINE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325
Mailing Address - Country:US
Mailing Address - Phone:601-917-8001
Mailing Address - Fax:
Practice Address - Street 1:11790 PINE GROVE RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39325
Practice Address - Country:US
Practice Address - Phone:601-917-8001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2783235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist