Provider Demographics
NPI:1598947475
Name:SPEECH PATHOLOGY SERVICES
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-226-0101
Mailing Address - Street 1:PO BOX 891
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38902-0891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1321 SUNSET DRIVE
Practice Address - Street 2:STE DD
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901
Practice Address - Country:US
Practice Address - Phone:662-226-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSSO798235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016200Medicaid