Provider Demographics
NPI:1598259376
Name:SPEECH AT THE BEACH
Entity Type:Organization
Organization Name:SPEECH AT THE BEACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:419-651-6368
Mailing Address - Street 1:1910 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3610
Mailing Address - Country:US
Mailing Address - Phone:419-651-6368
Mailing Address - Fax:850-279-3298
Practice Address - Street 1:1910 OAK AVE
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3610
Practice Address - Country:US
Practice Address - Phone:419-651-6368
Practice Address - Fax:850-279-3298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12063235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009331400Medicaid