Provider Demographics
NPI:1598891483
Name:EASTSIDE SPEECH AND PATHOLOGY
Entity Type:Organization
Organization Name:EASTSIDE SPEECH AND PATHOLOGY
Other - Org Name:EASTSIDES SPEECH AND THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRANGER
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:954-565-4437
Mailing Address - Street 1:840 E OAKLAND PARK BLVD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-2767
Mailing Address - Country:US
Mailing Address - Phone:954-565-4437
Mailing Address - Fax:954-565-4476
Practice Address - Street 1:840 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-2767
Practice Address - Country:US
Practice Address - Phone:954-565-4437
Practice Address - Fax:954-565-4476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2007001985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty