Provider Demographics
NPI:1730646639
Name:SELF, LINDSEY DIANNE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LINDSEY
Middle Name:DIANNE
Last Name:SELF
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 CHILDRE RD
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-4403
Mailing Address - Country:US
Mailing Address - Phone:601-953-5786
Mailing Address - Fax:
Practice Address - Street 1:355 CROSSGATES BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042-2602
Practice Address - Country:US
Practice Address - Phone:601-825-3192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4302235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist