Provider Demographics
NPI:1114053998
Name:WHELAN, CONNIE R (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:WHELAN
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 1:1211 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-4028
Mailing Address - Country:US
Mailing Address - Phone:662-453-5066
Mailing Address - Fax:662-455-3524
Practice Address - Street 1:702 HIGHWAY 82 W
Practice Address - Street 2:SUITE B
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5069
Practice Address - Country:US
Practice Address - Phone:662-455-5010
Practice Address - Fax:662-455-5468
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01327251Medicaid