Provider Demographics
NPI:1972010122
Name:THERASPEECH LLC
Entity Type:Organization
Organization Name:THERASPEECH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:765-465-8314
Mailing Address - Street 1:9314 N PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47386-9502
Mailing Address - Country:US
Mailing Address - Phone:765-465-8314
Mailing Address - Fax:
Practice Address - Street 1:9314 N PRAIRIE RD
Practice Address - Street 2:
Practice Address - City:SPRINGPORT
Practice Address - State:IN
Practice Address - Zip Code:47386-9502
Practice Address - Country:US
Practice Address - Phone:765-465-8314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004787A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201298110Medicaid