Provider Demographics
NPI:1265645147
Name:IRISH, CYNTHIA (SLP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:IRISH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6828 NW GRANGER AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1305
Mailing Address - Country:US
Mailing Address - Phone:772-215-0255
Mailing Address - Fax:
Practice Address - Street 1:3496 NW FEDERAL HWY STE G
Practice Address - Street 2:
Practice Address - City:JENSEN BEACH
Practice Address - State:FL
Practice Address - Zip Code:34957-4441
Practice Address - Country:US
Practice Address - Phone:772-223-5677
Practice Address - Fax:772-223-4997
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist