Provider Demographics
NPI:1164694147
Name:BOOMER, VANESSA YVONNE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:YVONNE
Last Name:BOOMER
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 1:727 ALMOO ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 N WEST END ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-3002
Practice Address - Country:US
Practice Address - Phone:479-750-8859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-30
Last Update Date:2008-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP2260235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist