Basic Information
| Provider Information | |||||||||
| NPI: | 1295776763 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPEECH PATHOLOGY ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1595 LINKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | ATLANTIC BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322337308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046353179 | ||||||||
| FaxNumber: | 9042467259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1463 NECTARINE ST | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320343027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046353179 | ||||||||
| FaxNumber: | 9042467259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/SPEECH PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 9046353179 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA3317 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | S1829 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER |