Provider Demographics
NPI:1568162147
Name:HOLCOMB, MIA M (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:M
Last Name:HOLCOMB
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 1:2127 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4461
Mailing Address - Country:US
Mailing Address - Phone:580-320-8599
Mailing Address - Fax:
Practice Address - Street 1:2127 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4461
Practice Address - Country:US
Practice Address - Phone:580-320-8599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5912235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist