Provider Demographics
NPI:1659755528
Name:OLIVE BRANCH SPEECH AND LANGUAGE SERVICES, PC
Entity Type:Organization
Organization Name:OLIVE BRANCH SPEECH AND LANGUAGE SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURICE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC/SLP-CI
Authorized Official - Phone:910-899-2585
Mailing Address - Street 1:115 AMBERLEIGH DR APT 301
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9846
Mailing Address - Country:US
Mailing Address - Phone:910-899-2585
Mailing Address - Fax:910-401-1555
Practice Address - Street 1:115 AMBERLEIGH DR APT 301
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9846
Practice Address - Country:US
Practice Address - Phone:910-899-2585
Practice Address - Fax:910-401-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10823235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty