Provider Demographics
NPI:1275877649
Name:MIRIAM ELIAS
Entity Type:Organization
Organization Name:MIRIAM ELIAS
Other - Org Name:IMAGINE SPEECH THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:305-538-4903
Mailing Address - Street 1:1030 NE 175TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33162-1237
Mailing Address - Country:US
Mailing Address - Phone:786-291-7330
Mailing Address - Fax:305-437-8052
Practice Address - Street 1:1030 NE 175TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33162
Practice Address - Country:US
Practice Address - Phone:786-291-7330
Practice Address - Fax:305-437-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889927400Medicaid