Provider Demographics
NPI:1639555881
Name:SPEECH PATHOLOGY GROUP LLC
Entity Type:Organization
Organization Name:SPEECH PATHOLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMORAJCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:475-239-5512
Mailing Address - Street 1:100 BEARD SAWMILL RD STE 282
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6175
Mailing Address - Country:US
Mailing Address - Phone:475-239-5512
Mailing Address - Fax:
Practice Address - Street 1:100 BEARD SAWMILL RD STE 282
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6175
Practice Address - Country:US
Practice Address - Phone:475-239-5512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-10
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 225X00000X, 235Z00000X
CT003727235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty