Provider Demographics
NPI:1023257342
Name:STURDIVANT, VIRGINIA RYLES (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:RYLES
Last Name:STURDIVANT
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:CLAIRE
Other - Last Name:RYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1325 SE 25TH LOOP
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-6090
Mailing Address - Country:US
Mailing Address - Phone:352-870-2221
Mailing Address - Fax:
Practice Address - Street 1:1325 SE 25TH LOOP
Practice Address - Street 2:SUITE 102
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-6090
Practice Address - Country:US
Practice Address - Phone:352-870-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-10
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI15682355S0801X
FLSZ5402235Z00000X
FLSA11623235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014569900Medicaid