Basic Information
| Provider Information | |||||||||
| NPI: | 1053353839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANMERSBERGEN | ||||||||
| FirstName: | MIRIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAN MERSBERGEN | ||||||||
| OtherFirstName: | MIRIAM | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | SLP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 850 POPLAR AVE BLDG 2 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381054607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012875565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4055 N PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381528011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016782009 | ||||||||
| FaxNumber: | 9016785497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 6315 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.