Provider Demographics
NPI:1376746388
Name:CONDON, LARITA M (SLP)
Entity Type:Individual
Prefix:
First Name:LARITA
Middle Name:M
Last Name:CONDON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:45869-1423
Mailing Address - Country:US
Mailing Address - Phone:419-629-2791
Mailing Address - Fax:
Practice Address - Street 1:253 W SIXTH ST
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865
Practice Address - Country:US
Practice Address - Phone:419-501-2165
Practice Address - Fax:419-501-2166
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP4804235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000523170OtherBLUE CROSS BLUE SHIELD
OH2781431Medicaid
OH000000523170OtherBLUE CROSS BLUE SHIELD
OH2781431Medicaid