Provider Demographics
NPI:1508342486
Name:COLLINS, TAMARA ROSE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ROSE
Last Name:COLLINS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E FOURTH ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-6211
Mailing Address - Country:US
Mailing Address - Phone:228-234-7988
Mailing Address - Fax:
Practice Address - Street 1:416 E FOURTH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-6211
Practice Address - Country:US
Practice Address - Phone:228-234-7988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0894235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSSO894OtherMISSISSIPPI STATE LICENSURE