Healthcare Provider Details

I. General information

NPI: 1093063455
Provider Name (Legal Business Name): CHERYL DIANNE HAWLEY MA/CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 I 55 N HIGHLAND VILLAGE STE 291
JACKSON MS
39211-5930
US

IV. Provider business mailing address

240 GREENSVIEW DR
BRANDON MS
39047-7681
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax:
Mailing address:
  • Phone: 769-572-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS3699
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: