Provider Demographics
NPI:1215395793
Name:SPECIALIZED SPEECH THERAPY
Entity Type:Organization
Organization Name:SPECIALIZED SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:PAYNE-MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP, MPH, SL
Authorized Official - Phone:228-861-0584
Mailing Address - Street 1:14553 S COUNTRY WOOD DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-8716
Mailing Address - Country:US
Mailing Address - Phone:228-861-0584
Mailing Address - Fax:
Practice Address - Street 1:14553 S COUNTRY WOOD DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-8716
Practice Address - Country:US
Practice Address - Phone:228-861-0584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS1120235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty