Provider Demographics
NPI:1225688047
Name:FORGOTTEN COAST SPEECH, LANGUAGE, AND SWALLOWING REHAB LLC
Entity Type:Organization
Organization Name:FORGOTTEN COAST SPEECH, LANGUAGE, AND SWALLOWING REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:352-538-6177
Mailing Address - Street 1:42 EVENING STAR DR
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327-0686
Mailing Address - Country:US
Mailing Address - Phone:352-538-6177
Mailing Address - Fax:
Practice Address - Street 1:42 EVENING STAR DR
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-0686
Practice Address - Country:US
Practice Address - Phone:352-538-6177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-13
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015670500Medicaid