Basic Information
Provider Information | |||||||||
NPI: | 1063184067 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOCKINGBIRD SPEECH CONNECTIONS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2500 BROOME ST | ||||||||
Address2: |   | ||||||||
City: | NOLENSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 371355020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102572429 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 BROOME ST | ||||||||
Address2: |   | ||||||||
City: | NOLENSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 371355020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102572429 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2021 | ||||||||
LastUpdateDate: | 09/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPARKS | ||||||||
AuthorizedOfficialFirstName: | KATHARINE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/SPEECH PATHOLOGIST | ||||||||
AuthorizedOfficialTelephone: | 9102572429 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S., CCC-SLP | ||||||||
NPICertificationDate: | 09/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.