Basic Information
| Provider Information | |||||||||
| NPI: | 1962036814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONNER | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARMEDELLE | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 750 ROYAL PALM CT | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328034229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9049551935 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1016 WILLA SPRINGS DR | ||||||||
| Address2: | |||||||||
| City: | WINTER SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327085214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076997999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2020 | ||||||||
| LastUpdateDate: | 03/01/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 15820 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.