Provider Demographics
NPI:1215273032
Name:UNIVERSITY OF SOUTHERN MISSISSIPPI
Entity type:Organization
Organization Name:UNIVERSITY OF SOUTHERN MISSISSIPPI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:EDS
Authorized Official - Phone:601-266-6378
Mailing Address - Street 1:118 COLLEGE DR BOX 5215
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39406-0001
Mailing Address - Country:US
Mailing Address - Phone:601-266-6378
Mailing Address - Fax:601-266-6763
Practice Address - Street 1:118 COLLEGE DR BOX 5215
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39406-0001
Practice Address - Country:US
Practice Address - Phone:601-266-6378
Practice Address - Fax:601-266-6763
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:USM DUBARD SCHOOL FOR LANGUAGE DISORDERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS1051235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty