Provider Demographics
NPI:1699225334
Name:BOCA GRANDE SPEECH THERAPY INC
Entity Type:Organization
Organization Name:BOCA GRANDE SPEECH THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ATHENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:602-460-9524
Mailing Address - Street 1:883 BELDEN ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-1168
Mailing Address - Country:US
Mailing Address - Phone:831-275-0792
Mailing Address - Fax:
Practice Address - Street 1:883 BELDEN ST APT 4
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-1168
Practice Address - Country:US
Practice Address - Phone:831-275-0792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP20818235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty