Provider Demographics
NPI:1942419775
Name:JMB SPEECH LANGUAGE AND PATHOLOGY SERVICES, INC
Entity Type:Organization
Organization Name:JMB SPEECH LANGUAGE AND PATHOLOGY SERVICES, INC
Other - Org Name:JEANNE M. BARTH SPEECH THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MGR.
Authorized Official - Prefix:MR
Authorized Official - First Name:EVERETT
Authorized Official - Middle Name:IVAN
Authorized Official - Last Name:NICELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-930-0197
Mailing Address - Street 1:3902 W HAMILTON AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614
Mailing Address - Country:US
Mailing Address - Phone:813-930-0197
Mailing Address - Fax:813-930-2426
Practice Address - Street 1:3902 W HAMILTON AVE STE 3
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:813-930-0197
Practice Address - Fax:818-930-0197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JMB SPEECH LANGUAGE AND PATHOLOGY SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-21
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1577235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686948396Medicaid
FL880866000Medicaid