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MSHA ID NUMBER:
FIRST NAME:
LAST NAME:
ADDRESS:
CITY:
STATE:
ZIP:
EMAIL:
COUNTY:
WORK PHONE:
HOME PHONE:
MS DEPT OF EDUCATION LICENSE:	None SLP A SLP/A
MS DEPT OF HEALTH LICENSE:	None SLP A SLP/A
Current ASHA member ?	No Yes
ASHA Certification	None SLP A SLP/A
Primary Occupational Setting	School Healthcare Private Practice University Other
List in MSHA online Member Directory ?	Yes No Member Directory is online and accessible only to MSHA members