Provider Demographics
NPI:1932494036
Name:WEESE, MYRANDA NOELLE (MA CF-SLP)
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:NOELLE
Last Name:WEESE
Suffix:
Gender:F
Credentials:MA CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W TYLER AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 E BARTON AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-2305
Practice Address - Country:US
Practice Address - Phone:870-735-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP8401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186790721Medicaid