Healthcare Provider Details

I. General information

NPI: 1003004664
Provider Name (Legal Business Name): ALICIA BROADWAY SWANN AUDIOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 HIGHWAY 80 W SUITE C
CLINTON MS
39056-4193
US

IV. Provider business mailing address

541 HIGHWAY 80 W AUDITORY PROCESSING CENTER
CLINTON MS
39056-4193
US

V. Phone/Fax

Practice location:
  • Phone: 601-488-4189
  • Fax: 601-488-4888
Mailing address:
  • Phone: 601-488-4189
  • Fax: 601-488-4888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA0955
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: