Provider Demographics
NPI:1710255492
Name:YOUR SPEECH THERAPIST, INC.
Entity Type:Organization
Organization Name:YOUR SPEECH THERAPIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:H
Authorized Official - Last Name:MITNICK
Authorized Official - Suffix:
Authorized Official - Credentials:MS/CCC-SLP
Authorized Official - Phone:954-778-8876
Mailing Address - Street 1:8178 SANDPIPER GLEN DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6946
Mailing Address - Country:US
Mailing Address - Phone:954-778-8876
Mailing Address - Fax:
Practice Address - Street 1:8178 SANDPIPER GLEN DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6946
Practice Address - Country:US
Practice Address - Phone:954-778-8867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2045235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty