Provider Demographics
NPI:1356644827
Name:SPEECH PATH SERVICES LLC
Entity Type:Organization
Organization Name:SPEECH PATH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:856-751-1937
Mailing Address - Street 1:901B ROUTE 73 N
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-1226
Mailing Address - Country:US
Mailing Address - Phone:609-410-4725
Mailing Address - Fax:856-751-1938
Practice Address - Street 1:901B ROUTE 73 N
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1226
Practice Address - Country:US
Practice Address - Phone:856-751-1937
Practice Address - Fax:856-751-1938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
NJ41YS00307500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1356644827Medicaid
NJ196764OtherPTAN