Provider Demographics
NPI:1588186829
Name:SPARC SPEECH AND LANGUAGE THERAPY SERVICES LLC
Entity Type:Organization
Organization Name:SPARC SPEECH AND LANGUAGE THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:MA-CCC-SLP
Authorized Official - Phone:313-268-6173
Mailing Address - Street 1:18640 MACK AVE # 127
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-7700
Mailing Address - Country:US
Mailing Address - Phone:313-268-6173
Mailing Address - Fax:
Practice Address - Street 1:1969 LOCHMOOR BLVD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1711
Practice Address - Country:US
Practice Address - Phone:313-268-6173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000566235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty