Provider Demographics
NPI:1508338989
Name:BACK BAY SPEECH THERAPY INC
Entity Type:Organization
Organization Name:BACK BAY SPEECH THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:631-514-5631
Mailing Address - Street 1:68 RUSSELL ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-1824
Mailing Address - Country:US
Mailing Address - Phone:617-807-0516
Mailing Address - Fax:
Practice Address - Street 1:68 RUSSELL ST UNIT 4
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:MA
Practice Address - Zip Code:02129-1824
Practice Address - Country:US
Practice Address - Phone:617-807-0516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
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
MA1720360498Medicaid