Provider Demographics
NPI:1164966529
Name:PORTLAND PEDIATRIC SPEECH THERAPY
Entity Type:Organization
Organization Name:PORTLAND PEDIATRIC SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHADORI
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:301-802-8342
Mailing Address - Street 1:341 HIGHLAND AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4510
Mailing Address - Country:US
Mailing Address - Phone:301-802-8342
Mailing Address - Fax:
Practice Address - Street 1:341 HIGHLAND AVE # 1
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4510
Practice Address - Country:US
Practice Address - Phone:301-802-8342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2317235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty