1922595800 NPI number — GWEN'S SPEECH THERAPY PC

Table of content: (NPI 1922595800)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922595800 NPI number — GWEN'S SPEECH THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GWEN'S SPEECH THERAPY PC
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:
1922595800
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 TERRELL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28734-8765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-371-3940
Provider Business Mailing Address Fax Number:
828-369-7497

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 TERRELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-371-3940
Provider Business Practice Location Address Fax Number:
828-369-3940
Provider Enumeration Date:
04/17/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FOWLER-BERKEN
Authorized Official First Name:
GWEN
Authorized Official Middle Name:
Authorized Official Title or Position:
SPEECH LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
828-332-7144

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  8653 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1447546312 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 741098 . This is a "HUMANA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9107845 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: ATN375312 , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 056344 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7413695 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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