Provider Demographics
NPI:1235673351
Name:CHISM, CARLA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:CHISM
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 1:2564 HIGHWAY 345
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863
Mailing Address - Country:US
Mailing Address - Phone:662-419-0934
Mailing Address - Fax:
Practice Address - Street 1:2564 HIGHWAY 345
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863
Practice Address - Country:US
Practice Address - Phone:662-419-0934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3362235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist