Provider Demographics
NPI:1073946786
Name:SPEECHWORKS 4 KIDS, INC.
Entity Type:Organization
Organization Name:SPEECHWORKS 4 KIDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT: SLP
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:M A, CCC-SLP
Authorized Official - Phone:478-213-4604
Mailing Address - Street 1:12026 LAKE DORIAN DR
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-6169
Mailing Address - Country:US
Mailing Address - Phone:478-213-4604
Mailing Address - Fax:571-379-8807
Practice Address - Street 1:12026 LAKE DORIAN DR
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-6169
Practice Address - Country:US
Practice Address - Phone:478-213-4604
Practice Address - Fax:571-379-8807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073946786Medicaid