Basic Information
Provider Information | |||||||||
NPI: | 1891242467 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOESTEN | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | EVAN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.A., CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1410 CATHERINE ST | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328014206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9548218684 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 644 FERGUSON DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328051023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8663114617 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/01/2016 | ||||||||
LastUpdateDate: | 03/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ 7715 | FL | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 235Z00000X | SA15983 | FL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | SA15983 | 01 | FL | FLORIDA SPEECH-LANGUAGE PATHOLOGY LICENSURE | OTHER | SP30125 | 01 | CA | CALIFORNIA SPEECH-LANGUAGE PATHOLOGY LICENSURE | OTHER | 018701300 | 05 | FL |   | MEDICAID | 2202009512 | 01 | VA | VIRGINIA SPEECH-LANGUAGE PATHOLOGY LICENSURE | OTHER |