Provider Demographics
NPI:1952852659
Name:SPEECH REHABILITATION SERVICES-DEMENTIA & DYSPHAGIA SPECIALISTS
Entity Type:Organization
Organization Name:SPEECH REHABILITATION SERVICES-DEMENTIA & DYSPHAGIA SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC-SLP
Authorized Official - Phone:813-431-7064
Mailing Address - Street 1:1528 AVONDALE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33567-3682
Mailing Address - Country:US
Mailing Address - Phone:813-431-7064
Mailing Address - Fax:
Practice Address - Street 1:1528 AVONDALE RIDGE DR
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33567-3682
Practice Address - Country:US
Practice Address - Phone:813-431-7064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7606320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities