Provider Demographics
NPI:1356646665
Name:DYNAMIC SPEECH THERAPY, LLC
Entity Type:Organization
Organization Name:DYNAMIC SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KEENAN
Authorized Official - Middle Name:PAIGE
Authorized Official - Last Name:GLAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP, L
Authorized Official - Phone:571-244-0316
Mailing Address - Street 1:21751 LADBROKE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20166-9290
Mailing Address - Country:US
Mailing Address - Phone:571-244-0316
Mailing Address - Fax:703-421-1212
Practice Address - Street 1:21751 LADBROKE GROVE CT
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20166-9290
Practice Address - Country:US
Practice Address - Phone:571-244-0316
Practice Address - Fax:703-421-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004993235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty