Provider Demographics
NPI:1235350422
Name:SHAIK, MUMTAZ (SLP)
Entity Type:Individual
Prefix:
First Name:MUMTAZ
Middle Name:
Last Name:SHAIK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7594
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-0594
Mailing Address - Country:US
Mailing Address - Phone:252-443-0808
Mailing Address - Fax:252-451-9032
Practice Address - Street 1:1223 JULIAN R ALLSBROOK HWY
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-5126
Practice Address - Country:US
Practice Address - Phone:252-537-1215
Practice Address - Fax:252-537-1816
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2824235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412988Medicaid