Basic Information
| Provider Information | |||||||||
| NPI: | 1568029270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KENNEDY | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2153 DEPT 1947 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352870001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012924562 | ||||||||
| FaxNumber: | 6019746237 | ||||||||
| Practice Location | |||||||||
| Address1: | 6250 OLD CANTON RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392112946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019567280 | ||||||||
| FaxNumber: | 6019776244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2019 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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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 | S4467 | MS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.