Provider Demographics
NPI:1952665416
Name:FUNCTIONAL ORAL MOTOR AND FEEDING CONCEPTS LLC
Entity Type:Organization
Organization Name:FUNCTIONAL ORAL MOTOR AND FEEDING CONCEPTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:260-438-3586
Mailing Address - Street 1:6025 CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-438-3586
Mailing Address - Fax:260-432-7046
Practice Address - Street 1:6205 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1517
Practice Address - Country:US
Practice Address - Phone:260-438-3586
Practice Address - Fax:260-432-7046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-29
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200681320AMedicaid