Provider Demographics
NPI:1548214125
Name:SPEECH MASTERS THERAPY SERVICES
Entity Type:Organization
Organization Name:SPEECH MASTERS THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:919-821-1822
Mailing Address - Street 1:100 MONIE LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1560
Mailing Address - Country:US
Mailing Address - Phone:919-821-1822
Mailing Address - Fax:919-821-7779
Practice Address - Street 1:100 MONIE LN
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27601-1560
Practice Address - Country:US
Practice Address - Phone:919-821-1822
Practice Address - Fax:919-821-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130ATOtherBCBSGROUP PROVIDER NUMBER
NC7210822Medicaid