Provider Demographics
NPI:1093295370
Name:NOWELL, LARUALEE FANT (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LARUALEE
Middle Name:FANT
Last Name:NOWELL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:LAURALEE
Other - Middle Name:E
Other - Last Name:FANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:83 AIRWAYS PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5885
Mailing Address - Country:US
Mailing Address - Phone:662-349-8787
Mailing Address - Fax:662-349-8757
Practice Address - Street 1:83 AIRWAYS PL
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5885
Practice Address - Country:US
Practice Address - Phone:662-349-8787
Practice Address - Fax:662-349-8757
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist