Provider Demographics
NPI:1043547284
Name:HOLISTIC SPEECH THERAPY SERVICES
Entity Type:Organization
Organization Name:HOLISTIC SPEECH THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-463-2510
Mailing Address - Street 1:1013 ENON CT
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0431
Mailing Address - Country:US
Mailing Address - Phone:904-463-2510
Mailing Address - Fax:
Practice Address - Street 1:1013 ENON CT
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-0431
Practice Address - Country:US
Practice Address - Phone:904-463-2510
Practice Address - Fax:904-940-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA9049235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty