Provider Demographics
NPI:1073788691
Name:WEST ORANGE SPEECH PATHOLOGIST, INC.
Entity Type:Organization
Organization Name:WEST ORANGE SPEECH PATHOLOGIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SLP
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM-RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:407-298-5300
Mailing Address - Street 1:PO BOX 555907
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32855-5907
Mailing Address - Country:US
Mailing Address - Phone:407-298-5300
Mailing Address - Fax:407-296-0026
Practice Address - Street 1:6388 SILVER STAR RD STE 2E
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-3235
Practice Address - Country:US
Practice Address - Phone:407-298-5300
Practice Address - Fax:407-296-0026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1245235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL202579OtherAMERIGROUP
FL882834200Medicaid
FL18348OtherSTAYWELL / WELLCARE
FL880650196OtherMEDWAIVER