Provider Demographics
NPI:1710315833
Name:LIBERTY SPEECH PATHOLOGY CENTER, LLC
Entity Type:Organization
Organization Name:LIBERTY SPEECH PATHOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:865-397-2892
Mailing Address - Street 1:505 W HIGHWAY 25 70
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-6126
Mailing Address - Country:US
Mailing Address - Phone:865-397-2892
Mailing Address - Fax:
Practice Address - Street 1:505 W HIGHWAY 25 70
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-6126
Practice Address - Country:US
Practice Address - Phone:865-397-2892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty