1497385520 NPI number — ENRI FORT MS,CCC-SLP

Table of content: ENRI FORT MS,CCC-SLP (NPI 1497385520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497385520 NPI number — ENRI FORT MS,CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORT
Provider First Name:
ENRI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS,CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YAMASHITA FORT
Provider Other First Name:
ENRI
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS,CCC-SLP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1497385520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2024
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:
1992 LEWIS TURNER BLVD SUITE 1067 #255
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WALTON BEEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32547
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:
01/16/2020

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: 222Q00000X , with the licence number:  18378 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , with the licence number: SA18378 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117725200 , 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: SA18378 . This is a "DOH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 118480700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117493600 , 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".




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