Provider Demographics
NPI:1497241988
Name:SPEECH SPARK THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:SPEECH SPARK THERAPY SERVICES LLC
Other - Org Name:SPEECH SPARK SLP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIAN
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:314-690-8521
Mailing Address - Street 1:1241 STRASSNER DR APT 1402
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1876
Mailing Address - Country:US
Mailing Address - Phone:904-303-0183
Mailing Address - Fax:
Practice Address - Street 1:8764 ROSALIE AVE UNIT 440162
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-5026
Practice Address - Country:US
Practice Address - Phone:314-690-8521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-08
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017016066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty