Provider Demographics
NPI:1225250764
Name:ADVANCE SPEECH AND LANGUAGE CENTER
Entity Type:Organization
Organization Name:ADVANCE SPEECH AND LANGUAGE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:FAY
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:850-843-1052
Mailing Address - Street 1:629 SW MORRIS STEEN ROAD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32331
Mailing Address - Country:US
Mailing Address - Phone:850-843-1052
Mailing Address - Fax:
Practice Address - Street 1:214 NORTH WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32347
Practice Address - Country:US
Practice Address - Phone:850-843-1052
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8913235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892105900Medicaid