Provider Demographics
NPI:1568686517
Name:PEDIATRIC SPEECH AND LANGUAGE THERAPY
Entity Type:Organization
Organization Name:PEDIATRIC SPEECH AND LANGUAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:206-547-2500
Mailing Address - Street 1:2205 N 45TH ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6903
Mailing Address - Country:US
Mailing Address - Phone:206-547-2500
Mailing Address - Fax:
Practice Address - Street 1:2205 N 45TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6903
Practice Address - Country:US
Practice Address - Phone:206-547-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002837235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA043646631OtherAETNA PROVIDER ID
WA3646RAOtherREGENCE RIDER NUMBER
WA6466RAOtherREGENCE RIDER NUMBER
WA043646631OtherPREMERA PROVIDER ID