Provider Demographics
NPI:1215273990
Name:TRICORE SPEECH LLC
Entity type:Organization
Organization Name:TRICORE SPEECH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:DENICE
Authorized Official - Last Name:CAMPBELL-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:314-660-1690
Mailing Address - Street 1:4491 BESSIE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-2707
Mailing Address - Country:US
Mailing Address - Phone:314-660-1690
Mailing Address - Fax:314-389-4820
Practice Address - Street 1:4491 BESSIE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-2707
Practice Address - Country:US
Practice Address - Phone:314-660-1690
Practice Address - Fax:314-389-4820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty