Provider Demographics
NPI:1194054577
Name:WEST, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:
Other - Last Name:TIDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:111 CHASE ST
Mailing Address - Street 2:
Mailing Address - City:BYHALIA
Mailing Address - State:MS
Mailing Address - Zip Code:38611-7395
Mailing Address - Country:US
Mailing Address - Phone:662-838-3670
Mailing Address - Fax:662-838-3740
Practice Address - Street 1:111 CHASE ST
Practice Address - Street 2:
Practice Address - City:BYHALIA
Practice Address - State:MS
Practice Address - Zip Code:38611-7395
Practice Address - Country:US
Practice Address - Phone:662-838-3670
Practice Address - Fax:662-838-3740
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2870235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist