Provider Demographics
NPI:1104143247
Name:HART, DEBORAH KAY
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:KAY
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:PHIPPS
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1293 FIELD LARK LN NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2089
Mailing Address - Country:US
Mailing Address - Phone:601-823-5435
Mailing Address - Fax:
Practice Address - Street 1:6331 W PORT AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129-2415
Practice Address - Country:US
Practice Address - Phone:318-671-0310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-SLP599235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist