Provider Demographics
NPI:1134701048
Name:MOMENTUM SPEECH THERAPY INC
Entity Type:Organization
Organization Name:MOMENTUM SPEECH THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SEMETRAH
Authorized Official - Middle Name:ALIMA
Authorized Official - Last Name:KINCANNON
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:760-278-1484
Mailing Address - Street 1:12722 SILVER SPUR WAY
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7437
Mailing Address - Country:US
Mailing Address - Phone:760-694-3240
Mailing Address - Fax:
Practice Address - Street 1:15409 ANACAPA RD STE 409A
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2463
Practice Address - Country:US
Practice Address - Phone:760-278-1484
Practice Address - Fax:855-719-2558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty