Provider Demographics
NPI:1598533226
Name:FLOURISHING KIDS THERAPY & LACTATION LLC
Entity Type:Organization
Organization Name:FLOURISHING KIDS THERAPY & LACTATION LLC
Other - Org Name:FROM THE HEART FEEDING AND LACTATION LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PEDIATRIC FEEDING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:CLC, MS, CCC-SLP
Authorized Official - Phone:636-748-0170
Mailing Address - Street 1:1600 HERITAGE LNDG STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63303-8488
Mailing Address - Country:US
Mailing Address - Phone:636-748-0170
Mailing Address - Fax:
Practice Address - Street 1:1600 HERITAGE LNDG STE 201
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63303-8488
Practice Address - Country:US
Practice Address - Phone:636-748-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-12
Last Update Date:2024-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty