Provider Demographics
NPI:1518972041
Name:THERACOMM SPEECH THERAPY SVCS
Entity Type:Organization
Organization Name:THERACOMM SPEECH THERAPY SVCS
Other - Org Name:THERACOMM SPEECH THERAPY SERVICES LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:910-482-4819
Mailing Address - Street 1:6204 LAKE TRAIL DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-0502
Mailing Address - Country:US
Mailing Address - Phone:910-482-4819
Mailing Address - Fax:910-482-0637
Practice Address - Street 1:6204 LAKE TRAIL DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-0502
Practice Address - Country:US
Practice Address - Phone:910-482-4819
Practice Address - Fax:910-482-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1514235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7411025Medicaid
NC72828OtherBLUE CROSS BCBS