1114053998 NPI number — CONNIE R WHELAN M.S., CCC-SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114053998 NPI number — CONNIE R WHELAN M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHELAN
Provider First Name:
CONNIE
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114053998
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1211 RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38930-4028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-453-5066
Provider Business Mailing Address Fax Number:
662-455-3524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 HIGHWAY 82 W
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38930-5069
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-455-5010
Provider Business Practice Location Address Fax Number:
662-455-5468
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  S0417 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01327251 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com