Provider Demographics
NPI:1700974227
Name:LAUREL SPEECH, LANGUAGE AND HEARING CTR
Entity Type:Organization
Organization Name:LAUREL SPEECH, LANGUAGE AND HEARING CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH/LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:THAMES
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:601-426-6116
Mailing Address - Street 1:PO BOX 2694
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39442-2694
Mailing Address - Country:US
Mailing Address - Phone:601-426-6116
Mailing Address - Fax:601-425-5829
Practice Address - Street 1:KAMPERS ALLEY #3
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-426-6116
Practice Address - Fax:601-425-5829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS34S0303235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0901712Medicaid