Provider Demographics
NPI:1922446814
Name:ISOM, RENITA MONAE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:RENITA
Middle Name:MONAE
Last Name:ISOM
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:PO BOX 5663
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:38634-5663
Mailing Address - Country:US
Mailing Address - Phone:662-544-0156
Mailing Address - Fax:
Practice Address - Street 1:7160 TCHULAHOMA RD STE 4
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9266
Practice Address - Country:US
Practice Address - Phone:662-544-0156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist