Healthcare Provider Details

I. General information

NPI: 1962504662
Provider Name (Legal Business Name): DESIREE D MUTCHERSON MS,CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 KEATS DR 221
SPARTANBURG SC
29301-4956
US

IV. Provider business mailing address

PO BOX 310647
TAMPA FL
33680-0647
US

V. Phone/Fax

Practice location:
  • Phone: 813-545-3042
  • Fax:
Mailing address:
  • Phone: 813-545-3042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA5247
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5292
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP-1568
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: