Provider Demographics
NPI:1154672582
Name:AGAPE HARBOR SPEECH THERAPY AND REHABILITATION, PLLC
Entity Type:Organization
Organization Name:AGAPE HARBOR SPEECH THERAPY AND REHABILITATION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-999-6358
Mailing Address - Street 1:16195 W COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-5740
Mailing Address - Country:US
Mailing Address - Phone:602-999-6358
Mailing Address - Fax:623-234-2802
Practice Address - Street 1:16195 W COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-5740
Practice Address - Country:US
Practice Address - Phone:602-999-6358
Practice Address - Fax:623-234-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP-4062251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1992830244Medicare NSC