1720372535 NPI number — SPEECH LANGUAGE PAL, LLC

Table of content: (NPI 1720372535)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720372535 NPI number — SPEECH LANGUAGE PAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPEECH LANGUAGE PAL, 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:
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:
1720372535
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 252,
Provider Second Line Business Mailing Address:
110 EAGLE CANYON CIRCLE
Provider Business Mailing Address City Name:
LYONS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80540-0252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
303-548-4795
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 EAGLE CANYON CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYONS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80540-5011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
303-548-4795
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VANLEEUWEN
Authorized Official First Name:
ALISON
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
SPEECH LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
303-548-4795

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  01110546 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 21783543 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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