Provider Demographics
NPI:1013565779
Name:BETH INGRAM THERAPY SERVICES
Entity Type:Organization
Organization Name:BETH INGRAM THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CF-SLP
Authorized Official - Phone:757-386-3394
Mailing Address - Street 1:10598 ORANGE BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-7503
Mailing Address - Country:US
Mailing Address - Phone:757-386-3394
Mailing Address - Fax:
Practice Address - Street 1:2111 W SWANN AVE STE 100
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2478
Practice Address - Country:US
Practice Address - Phone:757-386-3394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSZ9227OtherPROVISIONAL LICENSE FOR SPEECH LANGUAGE PATHOLOGIST