Provider Demographics
NPI:1972058121
Name:EADS, CHRISTINE SUSAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:SUSAN
Last Name:EADS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17208 LONG BOAT LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32820-2701
Mailing Address - Country:US
Mailing Address - Phone:208-830-2143
Mailing Address - Fax:
Practice Address - Street 1:17208 LONG BOAT LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32820-2701
Practice Address - Country:US
Practice Address - Phone:208-830-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 12984235Z00000X
CASP 23994235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist