Provider Demographics
NPI:1710239843
Name:NORTHWEST MS SPEECH & HEARING, LLC
Entity Type:Organization
Organization Name:NORTHWEST MS SPEECH & HEARING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:662-891-2029
Mailing Address - Street 1:112 OLD LAKE CV
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-7637
Mailing Address - Country:US
Mailing Address - Phone:662-891-2029
Mailing Address - Fax:
Practice Address - Street 1:445 HIGHWAY 6 E
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-3001
Practice Address - Country:US
Practice Address - Phone:662-891-2029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-13
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3022235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02701818Medicaid