Provider Demographics
NPI:1578954962
Name:BAYSIDE SPEECH THERAPY, INC.
Entity Type:Organization
Organization Name:BAYSIDE SPEECH THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NCIOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP
Authorized Official - Phone:813-944-9594
Mailing Address - Street 1:3152 LITTLE RD # 174
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1864
Mailing Address - Country:US
Mailing Address - Phone:727-777-7576
Mailing Address - Fax:
Practice Address - Street 1:11864 CRESTRIDGE LOOP
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-0018
Practice Address - Country:US
Practice Address - Phone:813-944-9594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-07
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT13073225X00000X
FLSA10890235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014254700Medicaid