Basic Information
| Provider Information | |||||||||
| NPI: | 1841598927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS-ALLEN | ||||||||
| FirstName: | TEQUESTA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5230 E FOWLER AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336172147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133749414 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5230 E FOWLER AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336172147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133749414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2011 | ||||||||
| LastUpdateDate: | 02/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 235Z00000X | SA11628 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 003344700 | 05 | FL | MEDICAID |