Basic Information
| Provider Information | |||||||||
| NPI: | 1154541142 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KIDZ ZONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5250 W. ANDREW JOHNSON HWY. | ||||||||
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| City: | MORRISTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233187800 | ||||||||
| FaxNumber: | 4233173332 | ||||||||
| Practice Location | |||||||||
| Address1: | 466A EASTERN PLAZA SHOPPING CTR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378213108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236239997 | ||||||||
| FaxNumber: | 4236239909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | MARSHALL | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | SPEECH-LANGUAGE PATHOLGIST | ||||||||
| AuthorizedOfficialTelephone: | 4233187800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1620 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 5440980 | 05 | TN | MEDICAID |