MEDICARE: MRS. VONDA MACK CRISWELL M.A.,CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2986	NC

General Provider Information

NPI Number	:	1417089947
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VONDA MACK CRISWELL M.A.,CCC-SLP

Provider Business Mailing Address
First Line	:	4922 DAYSPRING DR
Second Line	:
City	:	MINT HILL
State	:	NC
Zip	:	28227-9305
Country	:	US
Telephone Number	:	704-649-0733
Fax Number	:

Provider Business Practice Location Address
First Line	:	4922 DAYSPRING DR
Second Line	:
City	:	MINT HILL
State	:	NC
Zip	:	28227-9305
Country	:	US
Telephone Number	:	704-649-0733
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2007
Last Update Date	:	10/01/2020

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Directions to “ MRS. VONDA MACK CRISWELL M.A.,CCC-SLP” Practice Location

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