Provider Demographics
NPI:1992170781
Name:SMALL TALK SPEECH AND LANGUAGE THERAPY, INC.
Entity type:Organization
Organization Name:SMALL TALK SPEECH AND LANGUAGE THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATBOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:601-754-4524
Mailing Address - Street 1:2085 ROBB STREET EXT W
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-7048
Mailing Address - Country:US
Mailing Address - Phone:601-754-4524
Mailing Address - Fax:601-385-3040
Practice Address - Street 1:103 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3901
Practice Address - Country:US
Practice Address - Phone:601-754-4524
Practice Address - Fax:601-385-3040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-06
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3363235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07201256Medicaid