Provider Demographics
NPI:1629306477
Name:SPEECH PATHOLOGY SERVICES, LLC
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MED, CCC-SLP
Authorized Official - Phone:405-640-7045
Mailing Address - Street 1:8524 S WESTERN AVE
Mailing Address - Street 2:SUITE - 112
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-9246
Mailing Address - Country:US
Mailing Address - Phone:405-640-7045
Mailing Address - Fax:405-702-9397
Practice Address - Street 1:8524 S WESTERN AVE
Practice Address - Street 2:SUITE - 112
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-9246
Practice Address - Country:US
Practice Address - Phone:405-640-7045
Practice Address - Fax:405-702-9397
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRENDA DAVIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty