Provider Demographics
NPI:1245787480
Name:SPEECH SPARK SERVICES, LLC
Entity Type:Organization
Organization Name:SPEECH SPARK SERVICES, LLC
Other - Org Name:SPEECH SPARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLAR
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:920-403-0103
Mailing Address - Street 1:1924 SINCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-7530
Mailing Address - Country:US
Mailing Address - Phone:920-403-0103
Mailing Address - Fax:888-631-0117
Practice Address - Street 1:1924 SINCLAIR DR
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-7530
Practice Address - Country:US
Practice Address - Phone:920-403-0103
Practice Address - Fax:888-631-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2614-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty