Provider Demographics
NPI:1962504662
Name:MUTCHERSON, DESIREE D (MS,CCC/SLP)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:D
Last Name:MUTCHERSON
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 310647
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33680-0647
Mailing Address - Country:US
Mailing Address - Phone:813-545-3042
Mailing Address - Fax:
Practice Address - Street 1:200 KEATS DR
Practice Address - Street 2:221
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-4956
Practice Address - Country:US
Practice Address - Phone:813-545-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5247235Z00000X
SC5292235Z00000X
HISP-1568235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681570796Medicaid
FL888523100Medicaid