Provider Demographics
NPI:1295953909
Name:KITSAP SPEECH LANGUAGE PATHOLOGY SERVICES
Entity type:Organization
Organization Name:KITSAP SPEECH LANGUAGE PATHOLOGY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TORGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS,CCC-SLP
Authorized Official - Phone:360-871-2076
Mailing Address - Street 1:2323 STEAMBOAT LOOP E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4833
Mailing Address - Country:US
Mailing Address - Phone:360-871-2076
Mailing Address - Fax:360-895-0203
Practice Address - Street 1:1008 BETHEL AVE
Practice Address - Street 2:SUITE E
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4235
Practice Address - Country:US
Practice Address - Phone:360-871-2076
Practice Address - Fax:306-895-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003353235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7127236Medicaid