1902195712 NPI number — PARADISE COAST SPEECH THERAPY, LLC

Table of content: (NPI 1902195712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902195712 NPI number — PARADISE COAST SPEECH THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARADISE COAST SPEECH 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:
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:
1902195712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1289 SPERLING CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPLES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34103-2328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-580-8884
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 SPERLING CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPLES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34103-2328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-580-8884
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PENN
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
B
Authorized Official Title or Position:
SPEECH LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
239-580-8884

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SA 10710 , 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: SA 10710 . This is a "STATE OF FLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 01101838 . This is a "AMERICAN SPEECH LANGUAGE HEARING ASSOCIATION" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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