Provider Demographics
NPI:1265727598
Name:PHENOM SPEECH THERAPY, LLC
Entity type:Organization
Organization Name:PHENOM SPEECH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RILLING
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC-SLP
Authorized Official - Phone:208-919-4189
Mailing Address - Street 1:9850 S MARYLAND PKWY
Mailing Address - Street 2:STE A-5 #264
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-7146
Mailing Address - Country:US
Mailing Address - Phone:702-985-8385
Mailing Address - Fax:
Practice Address - Street 1:9937 DELICATE DEW ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89183-7153
Practice Address - Country:US
Practice Address - Phone:702-985-8385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1264235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty