Healthcare Provider Details

I. General information

NPI: 1174685820
Provider Name (Legal Business Name): CHARISSE BLEVINS CRAIG M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 S 6TH ST
ODESSA DE
19730-2060
US

IV. Provider business mailing address

118 S 6TH ST
ODESSA DE
19730-2060
US

V. Phone/Fax

Practice location:
  • Phone: 302-376-4128
  • Fax:
Mailing address:
  • Phone: 302-376-4128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number01-0001323
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: