Healthcare Provider Details

I. General information

NPI: 1457394330
Provider Name (Legal Business Name): ALICE DYSON CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BALL STATE UNIVERSITY AC 104
MUNCIE IN
47306-0001
US

IV. Provider business mailing address

4115 W COVENTRY DR
MUNCIE IN
47304-2415
US

V. Phone/Fax

Practice location:
  • Phone: 765-285-8478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22003906A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: