Provider Demographics
NPI:1699467225
Name:RAWLS, DEMETRIA JACKSON (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:JACKSON
Last Name:RAWLS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 NW 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33319-7203
Mailing Address - Country:US
Mailing Address - Phone:757-676-5218
Mailing Address - Fax:
Practice Address - Street 1:4761 NW 65TH AVE
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-7203
Practice Address - Country:US
Practice Address - Phone:757-676-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6854235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist