Provider Demographics
NPI:1215470505
Name:COON, MISTY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:COON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 UNION CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:MS
Mailing Address - Zip Code:39652-9742
Mailing Address - Country:US
Mailing Address - Phone:601-810-1572
Mailing Address - Fax:
Practice Address - Street 1:4122 UNION CHURCH RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:MS
Practice Address - Zip Code:39652-9742
Practice Address - Country:US
Practice Address - Phone:601-810-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7508235Z00000X
MSS2097235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist