Basic Information
| Provider Information | |||||||||
| NPI: | 1497111959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TALK ACTIVE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TALK ACTIVE THERAPY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6900 S ORANGE BLOSSOM TRL | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328095745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214451287 | ||||||||
| FaxNumber: | 4073867448 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 S ORANGE BLOSSOM TRL | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328095745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214451287 | ||||||||
| FaxNumber: | 4073867448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2016 | ||||||||
| LastUpdateDate: | 11/21/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTEIRO | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | BETOVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3214007527 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
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.