Provider Demographics
NPI:1316393663
Name:INTEGRATED SPEECH PATHOLOGY, LLC
Entity Type:Organization
Organization Name:INTEGRATED SPEECH PATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:SPILLMAN
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:866-539-6685
Mailing Address - Street 1:26 SNEIDER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07059-7042
Mailing Address - Country:US
Mailing Address - Phone:908-256-3575
Mailing Address - Fax:
Practice Address - Street 1:786 MOUNTAIN BLVD STE 203B
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-6268
Practice Address - Country:US
Practice Address - Phone:866-539-6685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YSO O1580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01062059OtherASHA
NJYSO O1580OtherNJ STATE LICENSE NUMBER