Basic Information
| Provider Information | |||||||||
| NPI: | 1285637892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUDIOLOGY AND SPEECH PATHOLOGY, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3540 FOREST HILL BLVD | ||||||||
| Address2: | STE 205 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616494006 | ||||||||
| FaxNumber: | 5619696621 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 FOREST HILL BLVD | ||||||||
| Address2: | STE 205 | ||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334065878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616494006 | ||||||||
| FaxNumber: | 5619696621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRANT | ||||||||
| AuthorizedOfficialFirstName: | MEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616494006 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHLAND HEARING CENTERS, INC. | ||||||||
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| AuthorizedOfficialCredential: | AU.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 600037108 | 05 | FL | MEDICAID | T0938 | 01 | FL | BCBS | OTHER | 600037110 | 05 | FL | MEDICAID | 600037100 | 05 | FL | MEDICAID |