Provider Demographics
NPI:1417617309
Name:SPEECH PATHWAYS OF ST. JOHNS
Entity Type:Organization
Organization Name:SPEECH PATHWAYS OF ST. JOHNS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GUSSMANN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:908-770-5990
Mailing Address - Street 1:609 FORT WILLIAM DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5925
Mailing Address - Country:US
Mailing Address - Phone:908-770-5990
Mailing Address - Fax:
Practice Address - Street 1:12627 SAN JOSE BLVD STE 803
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8644
Practice Address - Country:US
Practice Address - Phone:908-770-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational MedicineGroup - Multi-Specialty