Provider Demographics
NPI:1063649499
Name:SPACE COAST SPEECH AND LANGUAGE, LLC
Entity Type:Organization
Organization Name:SPACE COAST SPEECH AND LANGUAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CAREY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:321-220-9405
Mailing Address - Street 1:741 DINNER ST NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2034
Mailing Address - Country:US
Mailing Address - Phone:321-220-9405
Mailing Address - Fax:
Practice Address - Street 1:3800 W EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-3285
Practice Address - Country:US
Practice Address - Phone:321-220-9405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-11
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9802261QA3000X, 261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QA3000XAmbulatory Health Care FacilitiesClinic/CenterAugmentative Communication