Provider Demographics
NPI:1518303239
Name:CHANDLER, GLENDA SHANE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:SHANE
Last Name:CHANDLER
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 1:4244 HIGHWAY 84 E
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-7381
Mailing Address - Country:US
Mailing Address - Phone:601-580-2341
Mailing Address - Fax:
Practice Address - Street 1:285 HOLMES PITTMAN RD
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-3166
Practice Address - Country:US
Practice Address - Phone:601-736-3111
Practice Address - Fax:601-444-5036
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS108839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS3247OtherMISSISSIPPI DEPT OF HEALTH