Provider Demographics
NPI:1558662692
Name:WHITE, MISTY DAWN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
Last Name:WHITE
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 1:900 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DARDANELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72834-3104
Mailing Address - Country:US
Mailing Address - Phone:479-229-4185
Mailing Address - Fax:479-229-5036
Practice Address - Street 1:900 N 4TH ST
Practice Address - Street 2:
Practice Address - City:DARDANELLE
Practice Address - State:AR
Practice Address - Zip Code:72834-3104
Practice Address - Country:US
Practice Address - Phone:479-229-4185
Practice Address - Fax:479-229-5036
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#2892235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist