Provider Demographics
NPI:1568614642
Name:ATLANTIC SPEECH THERAPY
Entity Type:Organization
Organization Name:ATLANTIC SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-652-5408
Mailing Address - Street 1:11512 LAKE MEAD AVE.
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-652-5408
Mailing Address - Fax:877-652-5052
Practice Address - Street 1:11512 LAKE MEAD AVE.
Practice Address - Street 2:SUITE 604
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-652-5408
Practice Address - Fax:877-652-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5968235Z00000X
FLSA9598235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty