Provider Demographics
NPI:1235490798
Name:SPEECHFUNDAMENTALS PLLC
Entity Type:Organization
Organization Name:SPEECHFUNDAMENTALS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:LOCKLEAR
Authorized Official - Last Name:BREWINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:910-733-5820
Mailing Address - Street 1:113 VANCE ST
Mailing Address - Street 2:P.O. BOX 3465
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-4505
Mailing Address - Country:US
Mailing Address - Phone:910-733-5820
Mailing Address - Fax:910-521-5505
Practice Address - Street 1:113 VANCE ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-4505
Practice Address - Country:US
Practice Address - Phone:910-733-5820
Practice Address - Fax:910-521-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-07-18
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
NC7413666Medicaid