Provider Demographics
NPI:1245589407
Name:SPEECH THERAPISTS OF OLD TOWN
Entity Type:Organization
Organization Name:SPEECH THERAPISTS OF OLD TOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAFRENIERE
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:703-535-7841
Mailing Address - Street 1:700 PRINCESS ST
Mailing Address - Street 2:#202
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2268
Mailing Address - Country:US
Mailing Address - Phone:703-535-7841
Mailing Address - Fax:703-535-7842
Practice Address - Street 1:700 PRINCESS ST
Practice Address - Street 2:#202
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2268
Practice Address - Country:US
Practice Address - Phone:703-535-7841
Practice Address - Fax:703-535-7842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty