Basic Information
| Provider Information | |||||||||
| NPI: | 1003004664 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWANN | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | BROADWAY | ||||||||
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| Credential: | AUDIOLOGIST | ||||||||
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| 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 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | A0955 | MS | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 00534872 | 05 | MS | MEDICAID |