Provider Demographics
NPI:1477635621
Name:POCONO SPEECH CENTER, LLC
Entity Type:Organization
Organization Name:POCONO SPEECH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:DE FINO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:570-421-2232
Mailing Address - Street 1:1219 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-2646
Mailing Address - Country:US
Mailing Address - Phone:570-421-2232
Mailing Address - Fax:570-421-1825
Practice Address - Street 1:1219 N 5TH ST
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2646
Practice Address - Country:US
Practice Address - Phone:570-421-2232
Practice Address - Fax:570-421-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL004836L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018260230003Medicaid
PAPO540401OtherBCBS GROUP ID #