Provider Demographics
NPI:1245711662
Name:RISE SPEECH-LANGUAGE PATHOLOGY SERVICES, LLC
Entity type:Organization
Organization Name:RISE SPEECH-LANGUAGE PATHOLOGY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SLP/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP, BCS-CL
Authorized Official - Phone:505-302-0095
Mailing Address - Street 1:15 CALLEJA MIRAMONTE
Mailing Address - Street 2:
Mailing Address - City:LAMY
Mailing Address - State:NM
Mailing Address - Zip Code:87540-9662
Mailing Address - Country:US
Mailing Address - Phone:505-919-8149
Mailing Address - Fax:
Practice Address - Street 1:1012 MARQUEZ PL STE 211
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1834
Practice Address - Country:US
Practice Address - Phone:505-302-0095
Practice Address - Fax:855-729-9346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLP4932235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM41432771Medicaid