Basic Information
Provider Information | |||||||||
NPI: | 1629668041 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOVACEVIC | ||||||||
FirstName: | CASEY | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS CCC SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 455 W WARREN AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | LONGWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 327504038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072600551 | ||||||||
FaxNumber: | 4072659590 | ||||||||
Practice Location | |||||||||
Address1: | 2705 REBECCA LN STE B | ||||||||
Address2: |   | ||||||||
City: | ORANGE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 327638336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072600551 | ||||||||
FaxNumber: | 4072659590 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/20/2021 | ||||||||
LastUpdateDate: | 01/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA17929 | FL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.