Basic Information
Provider Information
NPI: 1003004664
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SWANN
FirstName: ALICIA
MiddleName: BROADWAY
NamePrefix:  
NameSuffix:  
Credential: AUDIOLOGIST
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 541 HIGHWAY 80 W
Address2: AUDITORY PROCESSING CENTER
City: CLINTON
State: MS
PostalCode: 390564193
CountryCode: US
TelephoneNumber: 6014884189
FaxNumber: 6014884888
Practice Location
Address1: 541 HIGHWAY 80 W
Address2: SUITE C
City: CLINTON
State: MS
PostalCode: 390564193
CountryCode: US
TelephoneNumber: 6014884189
FaxNumber: 6014884888
Other Information
ProviderEnumerationDate: 10/09/2007
LastUpdateDate: 10/23/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
231H00000XA0955MSY Speech, Language and Hearing Service ProvidersAudiologist 

ID Information
IDTypeStateIssuerDescription
0053487205MS MEDICAID


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