Provider Demographics
NPI:1790851517
Name:VALLEY KIDS PEDIATRIC SPEECH-LANGUAGE THERAPY, LLC
Entity Type:Organization
Organization Name:VALLEY KIDS PEDIATRIC SPEECH-LANGUAGE THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:VAL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:907-745-2839
Mailing Address - Street 1:642 S ALASKA ST
Mailing Address - Street 2:STE. 203
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6342
Mailing Address - Country:US
Mailing Address - Phone:907-745-2839
Mailing Address - Fax:907-746-2889
Practice Address - Street 1:642 S ALASKA ST
Practice Address - Street 2:STE. 203
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6342
Practice Address - Country:US
Practice Address - Phone:907-745-2839
Practice Address - Fax:907-746-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK83235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKSP0172Medicaid