Basic Information
| Provider Information | |||||||||
| NPI: | 1518371509 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDS SPEECH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30903 W 10 MILE RD STE B | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483362615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488936192 | ||||||||
| FaxNumber: | 2484575490 | ||||||||
| Practice Location | |||||||||
| Address1: | 30903 W 10 MILE RD STE B | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488936192 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 10/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | GOMOLUCH | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | SPEECH LANGUAGE PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2488936192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MACCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 7101000940 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.