Provider Demographics
NPI:1487232393
Name:EXPRESS YOURSELF THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:EXPRESS YOURSELF THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUDLACIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-587-7314
Mailing Address - Street 1:635 DUPONT ST UNIT M
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2660
Mailing Address - Country:US
Mailing Address - Phone:518-429-8404
Mailing Address - Fax:
Practice Address - Street 1:635 DUPONT ST UNIT M
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2660
Practice Address - Country:US
Practice Address - Phone:518-429-8404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1811258718Medicaid