Provider Demographics
NPI:1679082390
Name:CHILTON, PAMELA (SPEECH-LANGUAGE PATH)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:CHILTON
Suffix:
Gender:F
Credentials:SPEECH-LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W FIRE DEPARTMENT RD
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-9753
Mailing Address - Country:US
Mailing Address - Phone:601-947-7165
Mailing Address - Fax:
Practice Address - Street 1:211 W FIRE DEPARTMENT RD
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-9753
Practice Address - Country:US
Practice Address - Phone:601-947-7165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS0470235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01034712OtherASHA NUMBER