Provider Demographics
NPI:1417089947
Name:CRISWELL, VONDA MACK (MA,CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:VONDA
Middle Name:MACK
Last Name:CRISWELL
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4922 DAYSPRING DR
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-9305
Mailing Address - Country:US
Mailing Address - Phone:704-649-0733
Mailing Address - Fax:
Practice Address - Street 1:4922 DAYSPRING DR
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9305
Practice Address - Country:US
Practice Address - Phone:704-649-0733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2986235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist