Provider Demographics
NPI:1003963588
Name:SPEECH PATHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:FINE
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:865-705-8688
Mailing Address - Street 1:1001 GLENNSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-1958
Mailing Address - Country:US
Mailing Address - Phone:865-705-8688
Mailing Address - Fax:
Practice Address - Street 1:1001 GLENNSHIRE DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-1958
Practice Address - Country:US
Practice Address - Phone:865-705-8688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2013-07-29
Deactivation Date:2008-08-01
Deactivation Code:
Reactivation Date:2013-07-29
Provider Licenses
StateLicense IDTaxonomies
TNSP0000002724235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5441005Medicaid
TN4166781OtherBCBST