Provider Demographics
NPI:1679656409
Name:INTERCEPT SPEECH AND LANGUAGE, LLC
Entity Type:Organization
Organization Name:INTERCEPT SPEECH AND LANGUAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CORNETA
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:520-459-8258
Mailing Address - Street 1:13428 MAXELLA AVE # 228
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5620
Mailing Address - Country:US
Mailing Address - Phone:520-459-8258
Mailing Address - Fax:520-459-8619
Practice Address - Street 1:1201 E FRY BLVD
Practice Address - Street 2:SUITE #1
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2600
Practice Address - Country:US
Practice Address - Phone:520-459-8258
Practice Address - Fax:520-459-8619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4673251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ968141OtherAHCCCS