Provider Demographics
NPI:1265024202
Name:SPONTANEOUS EXPRESSIONS LLC
Entity Type:Organization
Organization Name:SPONTANEOUS EXPRESSIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/SPEECH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHIEEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-262-8159
Mailing Address - Street 1:3612 PARKMILL DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-6473
Mailing Address - Country:US
Mailing Address - Phone:910-262-8159
Mailing Address - Fax:
Practice Address - Street 1:601 QUAIL VALLEY DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-8051
Practice Address - Country:US
Practice Address - Phone:512-843-3136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty