Provider Demographics
NPI:1053898254
Name:BREWER, LAKENDRA
Entity type:Individual
Prefix:
First Name:LAKENDRA
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3667
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3667
Mailing Address - Country:US
Mailing Address - Phone:662-680-3148
Mailing Address - Fax:662-620-9890
Practice Address - Street 1:4403 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5335
Practice Address - Country:US
Practice Address - Phone:228-762-8960
Practice Address - Fax:228-769-1810
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist