Provider Demographics
NPI:1518205574
Name:FUNDAMENTAL SPEECH THERAPY
Entity Type:Organization
Organization Name:FUNDAMENTAL SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:VAUGHN
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:910-742-0575
Mailing Address - Street 1:218 LONG JOHN SILVER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9675
Mailing Address - Country:US
Mailing Address - Phone:910-742-0575
Mailing Address - Fax:866-263-4369
Practice Address - Street 1:218 LONG JOHN SILVER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9675
Practice Address - Country:US
Practice Address - Phone:910-742-0575
Practice Address - Fax:866-263-4369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-26
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty