Healthcare Provider Details

I. General information

NPI: 1114316817
Provider Name (Legal Business Name): JAIMEE TYSON-MCOMIE CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S EXETER ST
BALTIMORE MD
21202-4365
US

IV. Provider business mailing address

2409 STRATFORD CROSSING DR
WINSTON SALEM NC
27103-6567
US

V. Phone/Fax

Practice location:
  • Phone: 877-804-6222
  • Fax:
Mailing address:
  • Phone: 208-965-4921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP-1926
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: