Provider Demographics
NPI:1487093035
Name:WHITLEY, AMETHYST (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMETHYST
Middle Name:
Last Name:WHITLEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 LAKE HARBOUR DR
Mailing Address - Street 2:#1140
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4300
Mailing Address - Country:US
Mailing Address - Phone:601-906-6888
Mailing Address - Fax:
Practice Address - Street 1:711 LAKE HARBOUR DR
Practice Address - Street 2:#1140
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4300
Practice Address - Country:US
Practice Address - Phone:601-906-6888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3718235Z00000X
MO2013002841235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist