Healthcare Provider Details

I. General information

NPI: 1508623885
Provider Name (Legal Business Name): CARLY CHITTOM M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2203 HIGHWAY 72 E
CORINTH MS
38834-8859
US

IV. Provider business mailing address

2203 HIGHWAY 72 E
CORINTH MS
38834-8859
US

V. Phone/Fax

Practice location:
  • Phone: 662-872-3177
  • Fax:
Mailing address:
  • Phone: 662-872-3177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS5161
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: