Provider Demographics
NPI:1023365194
Name:AMERICAN RIVER SPEECH
Entity Type:Organization
Organization Name:AMERICAN RIVER SPEECH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGELLEKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-631-0428
Mailing Address - Street 1:11344 COLOMA RD
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11344 COLOMA RD
Practice Address - Street 2:
Practice Address - City:GOLD RIVER
Practice Address - State:CA
Practice Address - Zip Code:95670-4457
Practice Address - Country:US
Practice Address - Phone:916-631-0428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 3598235Z00000X
CASP 16930235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty