Provider Demographics
NPI:1346571155
Name:MCILWAIN, MILDRED ZUSSELLY (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:ZUSSELLY
Last Name:MCILWAIN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:MILDRED
Other - Middle Name:SUSIE
Other - Last Name:MCILWAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:5972 DAHOON DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-3246
Mailing Address - Country:US
Mailing Address - Phone:850-696-7583
Mailing Address - Fax:
Practice Address - Street 1:5972 DAHOON DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-3246
Practice Address - Country:US
Practice Address - Phone:850-696-7583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11004222Q00000X, 235Z00000X
NMSLP7100235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty