Healthcare Provider Details

I. General information

NPI: 1962123695
Provider Name (Legal Business Name): CAITLYN MIZELLE MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 AULENBROCK DR
CANTON MS
39046-7061
US

IV. Provider business mailing address

141 CHOCTAW BND
CLINTON MS
39056-3164
US

V. Phone/Fax

Practice location:
  • Phone: 601-521-4934
  • Fax:
Mailing address:
  • Phone: 601-951-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: