Provider Demographics
NPI:1124356605
Name:SPEECH THERAPY FOR KIDS, LLC
Entity Type:Organization
Organization Name:SPEECH THERAPY FOR KIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:LONG
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:662-574-2634
Mailing Address - Street 1:923 LIVE OAK LN
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-8565
Mailing Address - Country:US
Mailing Address - Phone:662-574-2634
Mailing Address - Fax:662-338-5439
Practice Address - Street 1:501 HIGHWAY 12 W STE A&D
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3654
Practice Address - Country:US
Practice Address - Phone:662-574-2634
Practice Address - Fax:662-338-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2545235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07384811Medicaid