Provider Demographics
NPI:1619156239
Name:CHEATHAM, KARISSA (MACCC/SOP)
Entity Type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:
Last Name:CHEATHAM
Suffix:
Gender:F
Credentials:MACCC/SOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854
Mailing Address - Country:US
Mailing Address - Phone:870-772-3371
Mailing Address - Fax:870-773-2602
Practice Address - Street 1:3435 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854
Practice Address - Country:US
Practice Address - Phone:870-772-3371
Practice Address - Fax:870-773-2602
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist