Provider Demographics
NPI:1114244183
Name:ORLANDO STUTTERING CENTER
Entity Type:Organization
Organization Name:ORLANDO STUTTERING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:CCC/SLP
Authorized Official - Phone:407-619-7548
Mailing Address - Street 1:4401 E COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5200
Mailing Address - Country:US
Mailing Address - Phone:407-619-7548
Mailing Address - Fax:407-898-5185
Practice Address - Street 1:4401 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5200
Practice Address - Country:US
Practice Address - Phone:407-619-7548
Practice Address - Fax:407-898-5185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6265235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888245100Medicaid