Provider Demographics
NPI:1477908390
Name:21C SPEECH- LANGUAGE TELEPRACTICE
Entity Type:Organization
Organization Name:21C SPEECH- LANGUAGE TELEPRACTICE
Other - Org Name:21C SPEECH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/ OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC/ SLP
Authorized Official - Phone:859-582-3659
Mailing Address - Street 1:543 GENERAL CRUFT DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7520
Mailing Address - Country:US
Mailing Address - Phone:859-582-3659
Mailing Address - Fax:
Practice Address - Street 1:543 GENERAL CRUFT DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-7520
Practice Address - Country:US
Practice Address - Phone:859-582-3659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2151235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty