Basic Information
| Provider Information | |||||||||
| NPI: | 1811449572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PERFORMING ARTS TRAINING ACADEMY, LLC | ||||||||
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| OtherOrganizationName: | PATA REHABILITATION SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1388 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702888881 | ||||||||
| FaxNumber: | 5702888065 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N WILKES BARRE BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187025253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704069083 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2016 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | TELLIS | ||||||||
| AuthorizedOfficialFirstName: | CARI | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5704069083 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL006394L | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.