1366140568 NPI number — LOGOS COMMUNICATION THERAPY SERVICES, LLC

Table of content: (NPI 1366140568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366140568 NPI number — LOGOS COMMUNICATION THERAPY SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGOS COMMUNICATION THERAPY SERVICES, 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:
1366140568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 BLACK BEAR CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-830-3314
Provider Business Mailing Address Fax Number:
850-904-0355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 BLACK BEAR CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-830-3314
Provider Business Practice Location Address Fax Number:
850-904-0355
Provider Enumeration Date:
02/17/2023

Additional Information

Authorized Official

Authorized Official Last Name:
FORT
Authorized Official First Name:
ENRI
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
850-830-3314

Provider Taxonomy Codes

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

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

  • Identifier: 118480700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: SA18378 . This is a "DOH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 117493600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117725200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118599100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 12030298 . This is a "ASHA CCC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 18378 . This is a "FL DOH SLP LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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