Provider Demographics
NPI:1649586157
Name:SMALL TALK SPEECH THERAPY LLC
Entity Type:Organization
Organization Name:SMALL TALK SPEECH THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:260-625-4323
Mailing Address - Street 1:2229 CALAIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9179
Mailing Address - Country:US
Mailing Address - Phone:260-625-4323
Mailing Address - Fax:260-625-3179
Practice Address - Street 1:2229 CALAIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9179
Practice Address - Country:US
Practice Address - Phone:260-625-4323
Practice Address - Fax:260-625-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003447A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty