Provider Demographics
NPI:1619417193
Name:OPAL SPEECH CLINIC PLLC
Entity Type:Organization
Organization Name:OPAL SPEECH CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:TRILBY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:580-327-0091
Mailing Address - Street 1:921 OKLAHOMA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-2631
Mailing Address - Country:US
Mailing Address - Phone:580-220-7461
Mailing Address - Fax:580-327-0091
Practice Address - Street 1:921 OKLAHOMA BLVD
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717-2631
Practice Address - Country:US
Practice Address - Phone:580-220-7461
Practice Address - Fax:580-327-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2325235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK01111392OtherASHA LICENSE
OK100677360DMedicaid