Provider Demographics
NPI:1346099165
Name:POINDEXTER, BRANDY DIANE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:DIANE
Last Name:POINDEXTER
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 1:527 MATTHEW ST
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2127
Mailing Address - Country:US
Mailing Address - Phone:662-223-0698
Mailing Address - Fax:
Practice Address - Street 1:30 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1158
Practice Address - Country:US
Practice Address - Phone:662-223-0698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA21452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist