Provider Demographics
NPI:1093467466
Name:SPACE SPEECH THERAPY, LLC
Entity Type:Organization
Organization Name:SPACE SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KIANA
Authorized Official - Middle Name:DESIREE
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:404-482-2947
Mailing Address - Street 1:850 S GADSDEN ST UNIT 729
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-2442
Mailing Address - Country:US
Mailing Address - Phone:678-517-9255
Mailing Address - Fax:
Practice Address - Street 1:850 S GADSDEN ST UNIT 729
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-2442
Practice Address - Country:US
Practice Address - Phone:678-517-9255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech