Provider Demographics
NPI:1891004115
Name:DYCUS, MANDY KAY (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:MANDY
Middle Name:KAY
Last Name:DYCUS
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 1:951 HWY 84 E
Mailing Address - Street 2:
Mailing Address - City:AMITY
Mailing Address - State:AR
Mailing Address - Zip Code:71921-8360
Mailing Address - Country:US
Mailing Address - Phone:501-337-6756
Mailing Address - Fax:870-398-5569
Practice Address - Street 1:320 SOUTHSIDE RD
Practice Address - Street 2:
Practice Address - City:ODEN
Practice Address - State:AR
Practice Address - Zip Code:71961-8091
Practice Address - Country:US
Practice Address - Phone:501-337-6756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR #1502235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140893721Medicaid