Provider Demographics
NPI:1326582313
Name:MST KIDS LLC
Entity Type:Organization
Organization Name:MST KIDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-283-5884
Mailing Address - Street 1:12030 SW 123RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12030 SW 123RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5156
Practice Address - Country:US
Practice Address - Phone:305-283-5884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty