Provider Demographics
NPI:1881862746
Name:ACEBO SPEECH AND LANGUAGE SERVICES
Entity Type:Organization
Organization Name:ACEBO SPEECH AND LANGUAGE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:ACEBO
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:918-645-3020
Mailing Address - Street 1:510 N DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 N DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3801
Practice Address - Country:US
Practice Address - Phone:918-645-3020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2910235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2000025540AMedicaid