Provider Demographics
NPI:1922433424
Name:SOUTHERN SMALL TALK
Entity Type:Organization
Organization Name:SOUTHERN SMALL TALK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC/SLP
Authorized Official - Phone:601-527-5969
Mailing Address - Street 1:849 WILLOW GRANDE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8352
Mailing Address - Country:US
Mailing Address - Phone:601-527-5969
Mailing Address - Fax:
Practice Address - Street 1:849 WILLOW GRANDE CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8352
Practice Address - Country:US
Practice Address - Phone:601-527-5969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00726008Medicaid