Provider Demographics
NPI:1760119705
Name:SUNSHINE STATE SPEECH-LANGUAGE PATHOLOGY LLC
Entity Type:Organization
Organization Name:SUNSHINE STATE SPEECH-LANGUAGE PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS-KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:904-386-1012
Mailing Address - Street 1:79 SHERRY DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-5233
Mailing Address - Country:US
Mailing Address - Phone:904-386-1012
Mailing Address - Fax:
Practice Address - Street 1:79 SHERRY DR
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-5233
Practice Address - Country:US
Practice Address - Phone:904-386-1012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-01
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115056600Medicaid