1912614488 NPI number — LIVELY SPEECH AND LANGUAGE THERAPY, LLC

Table of content: (NPI 1912614488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912614488 NPI number — LIVELY SPEECH AND LANGUAGE THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVELY SPEECH AND LANGUAGE THERAPY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912614488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 NATURE WALK PKWY UNIT 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32092-3065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-729-6759
Provider Business Mailing Address Fax Number:
904-490-8549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 NATURE WALK PKWY UNIT 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32092-3065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-729-6759
Provider Business Practice Location Address Fax Number:
904-490-8549
Provider Enumeration Date:
11/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LIVELY
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO & FOUNDER
Authorized Official Telephone Number:
904-729-6759

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SA12730 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY KIMBERLY KENNELL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SA14057 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SARAH LIVELY" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SA20932 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY MALLORY ABERCROMBIE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SA19092 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SONYA OLSEN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SA19465 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY JULIANNE TRAUNER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SA15493 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY AJA WALKER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SA16825 . This is a "FL BOARD OF SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SAMANTHA REPALONE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 119427600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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