Provider Demographics
NPI:1528591302
Name:FRESH START SPEECH THERAPY SERVICES LLC.
Entity Type:Organization
Organization Name:FRESH START SPEECH THERAPY SERVICES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KHALILAH
Authorized Official - Middle Name:MIGNON
Authorized Official - Last Name:MARQUES
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:904-652-6165
Mailing Address - Street 1:9957 MOORINGS DR STE 301
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-2415
Mailing Address - Country:US
Mailing Address - Phone:904-652-6165
Mailing Address - Fax:833-241-4607
Practice Address - Street 1:9957 MOORINGS DR STE 301
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-2415
Practice Address - Country:US
Practice Address - Phone:904-652-6165
Practice Address - Fax:833-241-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Single Specialty