Provider Demographics
NPI: | 1821711805 |
---|---|
Name: | SPEECH ALLY, SPEECH PATHOLOGY CORPORATION |
Entity Type: | Organization |
Organization Name: | SPEECH ALLY, SPEECH PATHOLOGY CORPORATION |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | SPEECH LANGUAGE PATHOLOGIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JENNY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | TIPTON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MA CCC-SLP |
Authorized Official - Phone: | 970-640-0124 |
Mailing Address - Street 1: | 2178 BROOKWOOD AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | SANTA ROSA |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95404-7018 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 970-640-0124 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2178 BROOKWOOD AVE |
Practice Address - Street 2: | |
Practice Address - City: | SANTA ROSA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95404-7018 |
Practice Address - Country: | US |
Practice Address - Phone: | 970-640-0124 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-09-23 |
Last Update Date: | 2022-10-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Single Specialty |