Basic Information
| Provider Information | |||||||||
| NPI: | 1265668644 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEECH THERAPY ASSOCIATES OF MAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29 DEERING ST | ||||||||
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| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041012309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078990383 | ||||||||
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| Address1: | 29 DEERING ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041012309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078990383 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2009 | ||||||||
| LastUpdateDate: | 05/31/2009 | ||||||||
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| AuthorizedOfficialLastName: | POLLARD | ||||||||
| AuthorizedOfficialFirstName: | PENELOPE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SPEECH LANGUAGE PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2078990383 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | N/A | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.