=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295117083
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA MARIE HOLDAWAY M.S., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2015
-----------------------------------------------------
Last Update Date | 06/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 KY ROUTE 321 STE. 2208
-----------------------------------------------------
City | PRESTONSBURG
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41653-9113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-889-3586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 STACY ST APT 105
-----------------------------------------------------
City | HAROLD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41635-7061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-430-4278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLPLPA00218759
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------