Provider Demographics
NPI:1598117608
Name:MIDLANDS THERAPY
Entity Type:Organization
Organization Name:MIDLANDS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STATON
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:606-282-8270
Mailing Address - Street 1:PO BOX 139
Mailing Address - Street 2:207 RUSSELL STREET
Mailing Address - City:BURGIN
Mailing Address - State:KY
Mailing Address - Zip Code:40310-0139
Mailing Address - Country:US
Mailing Address - Phone:606-282-8270
Mailing Address - Fax:
Practice Address - Street 1:225 VISTA SPRINGS CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-8119
Practice Address - Country:US
Practice Address - Phone:803-359-3195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6023252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency