1245501824 NPI number — MRS. MARY LYNNE WEBB MCD CCC SLP

Table of content: MRS. MARY LYNNE WEBB MCD CCC SLP (NPI 1245501824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245501824 NPI number — MRS. MARY LYNNE WEBB MCD CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBB
Provider First Name:
MARY
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MCD 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:
1245501824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
642 HIGHWAY 258
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALD KNOB
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72010-9720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-203-5200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 W CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEEBE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72012-3103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-882-5463
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2012

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:  1014 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 189562795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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