Provider Demographics
NPI:1720581374
Name:MISSISSIPPI STATE UNIVERSITY
Entity Type:Organization
Organization Name:MISSISSIPPI STATE UNIVERSITY
Other - Org Name:T.K. MARTIN CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR SPEECH PATHOLOGIST AAC SPE
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CIRLOT-NEW
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC/SLP
Authorized Official - Phone:662-325-1029
Mailing Address - Street 1:P.O. BOX 9736
Mailing Address - Street 2:
Mailing Address - City:MISSISSIPPI STATE
Mailing Address - State:MS
Mailing Address - Zip Code:39762
Mailing Address - Country:US
Mailing Address - Phone:662-325-1028
Mailing Address - Fax:662-325-0896
Practice Address - Street 1:326 HARDY ROAD
Practice Address - Street 2:
Practice Address - City:MISSISSIPPI STATE
Practice Address - State:MS
Practice Address - Zip Code:39762
Practice Address - Country:US
Practice Address - Phone:662-325-1028
Practice Address - Fax:662-325-0896
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSTA2922224Z00000X
MSS0482235Z00000X
MSS0478235Z00000X
MSS2375235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty