Provider Demographics
NPI:1811286545
Name:ABBOTT, THOMAS MICHAEL (MSP, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:MSP, 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 188
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:AR
Mailing Address - Zip Code:72933-0188
Mailing Address - Country:US
Mailing Address - Phone:479-965-2460
Mailing Address - Fax:
Practice Address - Street 1:11 DALE BUMPERS DRIVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:AR
Practice Address - Zip Code:72933-0011
Practice Address - Country:US
Practice Address - Phone:479-965-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR309235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist