Provider Demographics
NPI:1467713750
Name:SPEECH DIVAS
Entity Type:Organization
Organization Name:SPEECH DIVAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:817-371-3353
Mailing Address - Street 1:4229 PERIWINKLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-3013
Mailing Address - Country:US
Mailing Address - Phone:469-834-5742
Mailing Address - Fax:
Practice Address - Street 1:4229 PERIWINKLE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-3013
Practice Address - Country:US
Practice Address - Phone:469-834-5742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-03
Last Update Date:2012-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX338912355S0801X
TX19126235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty