Basic Information
| Provider Information | |||||||||
| NPI: | 1861427783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAIN REGION SPEECH AND HEARING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LOUIS STREET | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376605195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232464600 | ||||||||
| FaxNumber: | 4232463311 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 LOUIS STREET | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376605195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232464600 | ||||||||
| FaxNumber: | 4232463311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/19/2011 | ||||||||
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| AuthorizedOfficialLastName: | SPIVEY | ||||||||
| AuthorizedOfficialFirstName: | MAVIS | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 4232464600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 004978048 | 05 | VA | MEDICAID |