Provider Demographics
NPI:1639580517
Name:RESTORATIVE SPEECH AND SWALLOW LLC
Entity Type:Organization
Organization Name:RESTORATIVE SPEECH AND SWALLOW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:P
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MPH, CCC-SLP
Authorized Official - Phone:215-360-8012
Mailing Address - Street 1:220 W EVERGREEN AVE
Mailing Address - Street 2:UNIT B-1
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-3862
Mailing Address - Country:US
Mailing Address - Phone:215-360-8012
Mailing Address - Fax:866-456-4839
Practice Address - Street 1:220 W EVERGREEN AVE
Practice Address - Street 2:UNIT B-1
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-3862
Practice Address - Country:US
Practice Address - Phone:215-360-8012
Practice Address - Fax:866-456-4839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-14
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL-005981-L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty