Provider Demographics
NPI:1114360039
Name:PREMIER PEDIATRIC THERAPY, P.A.
Entity Type:Organization
Organization Name:PREMIER PEDIATRIC THERAPY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAC
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:561-670-4864
Mailing Address - Street 1:1080 E INDIANTOWN RD STE 104
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-5188
Mailing Address - Country:US
Mailing Address - Phone:561-670-4864
Mailing Address - Fax:561-258-0812
Practice Address - Street 1:1080 E INDIANTOWN RD STE 104
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5188
Practice Address - Country:US
Practice Address - Phone:561-670-4864
Practice Address - Fax:561-258-0812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8369235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890294100Medicaid
FL003349800Medicaid