Provider Demographics
NPI:1326428764
Name:AUSTIN, SIEDAH
Entity Type:Individual
Prefix:
First Name:SIEDAH
Middle Name:
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4836 CHASTAIN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5062
Mailing Address - Country:US
Mailing Address - Phone:601-454-4877
Mailing Address - Fax:
Practice Address - Street 1:4836 CHASTAIN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5062
Practice Address - Country:US
Practice Address - Phone:601-454-4877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3711235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD12150448OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION