Provider Demographics
NPI:1083868574
Name:KOONCE/POWELL, VANESSA CAROLINE (MSE CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:CAROLINE
Last Name:KOONCE/POWELL
Suffix:
Gender:F
Credentials:MSE CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3690 GRESHAM DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7298
Mailing Address - Country:US
Mailing Address - Phone:501-327-1485
Mailing Address - Fax:
Practice Address - Street 1:101 BULLDOG DR
Practice Address - Street 2:
Practice Address - City:PLUMERVILLE
Practice Address - State:AR
Practice Address - Zip Code:72127-8803
Practice Address - Country:US
Practice Address - Phone:501-354-2269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist