Provider Demographics
NPI:1316526643
Name:MCINNISH, RAEGAN CAROLINE
Entity type:Individual
Prefix:
First Name:RAEGAN
Middle Name:CAROLINE
Last Name:MCINNISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSCLE SHOALS
Mailing Address - State:AL
Mailing Address - Zip Code:35661-1675
Mailing Address - Country:US
Mailing Address - Phone:256-702-0779
Mailing Address - Fax:
Practice Address - Street 1:405 E DR HICKS BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-5762
Practice Address - Country:US
Practice Address - Phone:256-767-1576
Practice Address - Fax:256-767-1577
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4866235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty