Healthcare Provider Details

I. General information

NPI: 1295108512
Provider Name (Legal Business Name): ELIZABETH BLANN LUTKEN MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W JACKSON ST
RIDGELAND MS
39157-2355
US

IV. Provider business mailing address

2457 WILD VALLEY DR
JACKSON MS
39211-6233
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-0859
  • Fax:
Mailing address:
  • Phone: 662-822-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS3866
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: