1255754560 NPI number — MS. JUDITH KROOVAND MASTERS IN SPEECH/LA

Table of content: MS. JUDITH KROOVAND MASTERS IN SPEECH/LA (NPI 1255754560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255754560 NPI number — MS. JUDITH KROOVAND MASTERS IN SPEECH/LA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KROOVAND
Provider First Name:
JUDITH
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MASTERS IN SPEECH/LA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1255754560
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12 CHIPPEWAY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32137-8934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-445-1150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4875 PALM COAST PKWY NW
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32137-3670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-446-9935
Provider Business Practice Location Address Fax Number:
386-446-7777
Provider Enumeration Date:
01/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2355S0801X , with the licence number:  SI2726 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X , with the licence number: SZ 6536 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: SI2726 . This is a "FLORIDA DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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